Columbia  Wini\}tvmv 
intf)eCitpofi^eh)|iorfe 

College  o(  pijpsiciang  anb  burgeons 


(gibenfap 

IBv,  Cbtoin  ]B.  Cragin 

1859-1918 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/operationsofsurg1889jaco 


THE 


OPERATIONS    OF   SURGERY. 


BOOKS  FOR  SURGEONS  and  STUDENTS, 

PUBLISHED   BY 

P.  BLAKISTON,  SON  &  CO.,  Philadelphia. 


CAIRD  AND  CATHCART,  a  Surgical  Handbook  for  the  use  of  Practitioners  and 
Students.  By  F.  Mitchell  Caird,  M.B.,  F.R.C.S.  (Edin.),  and  C.  Walker 
Cathcart,  M.B.,  F.R.C.S.  (Eng.  and  Edin.).  With  over  200  Illustrations. 
32mo.     400  pages,  pocket  size.     Full  Leather.  Jicst  Ready. 

HORWITZ'S  COMPEND  OF  SURGERY,  including  Minor  Surgery,  Amputa- 
tions, Fractures,  Dislocations,  Surgical  Diseases,  and  the  Latest  Antiseptic  Rules, 
etc.,  with  Differential  Diagnosis  and  Treatment.  By  Orville  Horwitz,  B.S., 
M.D.,  Demonstrator  of  Anatomy,  Jefferson  Medical  College  ;  Chief  Out-Patient 
Surgical  Department,  Jefferson  Medical  College  Hospital.  Third  Edition.  Very 
much  Enlarged  and  Rearranged.  91  Illustrations  and  77  Formulae.  i2mo.  No. 
Q  ?  Quiz   Compcnd?  Series.     Interleaved  for  the  addition  of  notes,  $1.25. 

Cloth.  ;fi.oo. 
"We  have  found  occasion  to  speak  highly  of  the  entire  series  of  Quiz  Compends 
as  far  as  issued.     This  little  work  has  met  with  such  favor  that  already  a  third  edition  is 
demanded.     The  author  has  improved  it  in  many  ways.    The  chapters  on  antiseptic  sur- 
gery, mortification   and   gangrene,  urethrotomj',  burns  and  scalds,  venereal  diseases, 
retention  of  urine   and   inflammation  have   been   re-written,  and   brought  thorough'y 
abreast  of  our  present  knowledge." — Buffalo  Medical  and  Surgical  Journal. 
AVALSHAM.     MANUAL   OF   PRACTICAL   SURGERY.     For   Students   and 
Physicians.     By  Wm.  J.  Walsham,  M.D.,  F.R.C.S.,  Asst.  Surg,  to,  and  Dem.  of 
Practical  Surg,  in  St.  Bartholomew's  Hospital,  Surg,  to  Metropolitan  Free  Hos- 
pital, London.     With  236  Engravings.     656  pages.     New  Series  0/  Manuals. 

Cloth,  $3.00  ;  Leather,  $3.50. 
"  While  in  no  sense  a  '  short  cut  to  surgery  '  Mr.  Walsham's  book  seems  to  be  in 
the  main  intended  as  a  manual  or  handbook  for  the  student  and  practitioner  of  surgery. 
The  subjects  with  which  every  student  ought  to  be  thoroughly  acquainted  are  given 
special  prominence,  while  the  rarer  forms  of  injury  and  disease  have  either  received  but 
short  notice  or  have  been  entirely  omittted.        ****** 

"  The  first  two  sections,  occupying  119  pages,  are  devoted  to  '  General  Pathology 
of  Surgical  Diseases,'  and  '  General  Pathology  of  Injuries  ;'  for  the  introduction  of 
which  into  a  manual  the  author  is  to  be  commended.  The  illustrations,  as  a  rule,  are 
good,  in  that  they  show  what  they  are  intended  to  represent.  Many  of  them  are  new, 
and  we  note  with  pleasure  the  conspicuous  paucity  of  many  too  familiar  old  ones.  The 
book  is  a  good  one,  and  written  in  Mr.  Walsham's  well-known  lucid  style." — fournal  o_f 
the  American  Medical  AssncitHnn- 


^^QyiQ>yrvuaiA\ 


THE 


OPERATIONS  OF  SURGERY 


SYSTEMATIC    HANDBOOK 


PKACTITIONERS,  STUDENTS  and  HOSPITAL  SURGEONS. 


W.  H.  A.  JACOBSON,  F.R.C.S., 

ASSISTANT-SURGEON  GUY'S  HOSPITAL;    TEACHER  OF  OPERATIVE  SURGERY,  AND  JOINT  TEACHER  OF 

PRACTICAL  SURGERY   IN  THE  MEDICAL  SCHOOL  ;  SURGEON  TO  THE  ROYAL 

HOSPITAL  FOR  CHILDREN  AND  WOMEN. 


ONE  HUNDRED  AND  NINETY-NINE  ILLUSTRATIONS. 


PHILADELPHIA: 

P.   BLAKISTON,   SON   &  CO., 

No.  1012  Walnut  Street. 
1889. 


SHEBMAN   &  CO.,  PRINTERS,  PHILADELPHIA. 


TO 

THREE     OLD     FRIENDS 

ARTHUR  EDWARD  DURHAM 
JAMES  FREDERIC  GOODHART 
EDWARD  CLIMSON  GREENWOOD 

3  JUcbicate  tins  Book 

AS     SOME     SLIGHT     TOKEN     OF     MY     GEATITUDE 
AND   AFFECTIONATE  RESPECT, 


► 


PREFACE. 

This  book  is  the  outcome  of  a  strong  belief,  which  I  have  held  for 
many  years,  that  a  work  on  Operative  Surgery  which  aimed  at  being 
more  comprehensive  in  scope  and  fuller  in  detail  than  those  already 
published,  would  be  of  service  to  Practitioners  and  Students. 

I  most  gladly  take  this  opportunity  of  acknowledging  my  good  for- 
tune in  being  able  to  profit  by  the  facile  pencil  and  the  cultivated 
knowledge  of  my  old  dresser  and  friend  Dr.  C.  W.  Hogarth,  of  Brix- 
ton. His  happy  combination  of  Art  and  Medicine,  and  his  friendly 
patience  iu  carrying  out  my  wishes,  have  been  to  me  a  saving  of 
much  trouble. 

To  Messrs.  Churchill  I  owe  the  opportunity  of  making  use  of  some 
of  those  drawings  by  Thomas  and  William  Bagg,  which  were  so  well 
known  in  the  pages  of  that  master  of  Surgery,  Sir  William  Fer- 
gusson. 

Great  Cumberland  Place, 
Hyde  Park.  W. 


k 


CONTENTS. 


PART  I. 

OPERATIONS  ON  THE  UPPER  EXTREMITY. 

CHAP.  PAGES 

I.  Operations  ON  THE  Hakd. — Amputations  of  fingers. — Amputations 
of  thumb.— Excision  of  thumb  and  fingers. — Reunion  of  severed 
digits. — Webbed  fingers. — Contracted  palmar  fascia. — Palmar  hse- 
morrhage. — Union  of  divided  tendons,    ......       17-40 

II.  Operations  on  the  Wrist. — Excision  of  the  wrist-joint. — Amputa- 
tion through  the  wrist-joint. — Ligature  of  radial  on  the  back  of  tli« 
wrist, ,         .      40-53 

III.  Operations  on  the  Forearm  — Ligature  of  radial  in  the  forearm. — 

Ligature  of  ulnar  in  the  forearm. — Excision  of  radius  and  ulna. — 
Amputation  of  forearm, 53-64 

IV.  Operations  in  the  Neighborhood  of  the  Ei,bow-.toint. — Am- 

putation at  elbow. — Excision  of  elbow. — Excision  of  superior  radio- 
ulnar joint, —  Ununited  fracture  of  olecranon. — Venesection. — 
Transfusion. — Ligature  of  the  brachial  at  the  bend  of  the  elbow,    ,       64-92 

V.  Operations  on  the  Arm. — Ligature  of  brachial  artery. — Amputa- 
tion of  arm. — Excision  in  continuity  of  the  shaft  of  the  humerus. — 
Operations  on  musculo-spiral  nerve,         ..,,..     92-105 

VI.  Operations  on  the  Axiixa  and  Shoulder. — Ligature  of  axil- 
lary artery. — Amputation  at  the  shoulder-joint.  —  Excision  of 
shoulder-joint, ,         .        ,   105-138 

VII.  Operations  on  the  Scapula. — Removal  of  the  scapula,       .        .  138-146 

VIII.  Operations  on  the  Clavicle. — Removal  of  the  clavicle. —  Un- 
united fracture  of  the  clavicle, 146-150 


10  CONTENTS. 

PART   II. 
OPERATIONS  ON  THE  HEAD  AND  NECK. 

CHAP.  PAGES 

I.  Operations  on  the  Scalp. — Fibro-cellular  tumors,  or  molluscum 
fibrosum. — -Aneurism  by  anastomosis. — Question  of  operative  inter- 
ference in  growths  of  the  cranial  bones  and  dura  mater,  .        .  151-155 

II.  Trephining. — Operative  interference  in  immediate  or  recent  frac- 
tures of  the  skull. — Trephining  in  fractured  skull. — Trephining  for 
pus  between  the  skull  and  dura  mater. — Trephining  for  middle  men- 
ingeal haemorrhage. — Trephining  and  exploration  of  cerebral  ab- 
scess due  to  injury. — Trephining  for  epilepsy  and  other  later  results 
of  a  cranial  injury. — Trepliining  for  mastoid  abscess  and  cerebral 
abscess,  the  results  of  otitis  media. — Operative  interference  in  the 
case  of  foreign  bodies  in  the  brain. — Trephining  frontal  sinuses,     .  156-209 

III.  Operations  on  the  Brain. — Cerebral  localization  in  reference  to 

operation. — Tumors  of  the  brain. —  Prof.  Horsley's  method  of  oper- 
ating on  the  brain, 209-230 

IV.  Operations  on  the  Face — Operations  on  the  fifth  nerve. — Stretch- 

ing the  facial  nerve. — Restoration  of  Steno's  duct. — Operative 
treatment  of  lupus. — Operative  treatment  of  rodent  ulcer. — Re- 
moval of  parotid  growths, 230-250 

V.  Excision  of  the  Eyeball  and  Clearing  out  of  the  Orbit,    .  250-254 

VI.  Operations  on  the  Nose. — Plastic  operations  for  the  repair  of  the 

nose. — Rouge's  operation. — Removal  of  nasal  polypi,     .        .        .  254-267 

VII.  Operations  on  the  Jaws. — Removal  of  upper  jaw,  partial  or  com- 
plete.— Operations  for  naso-pharyngeal  polypus. — Tapping  the 
antrum. — Removal  of  the  lower  jaw,  partial  or  complete. — Opera- 
tions to  relieve  fixity  of  the  lower  jaw,    ......  267-303 

VIII.  Operations   on    the    Lips.— Hare-lip. — Double    hare-lip. — Other 

plastic  operations  on  the  lips, 303-317 

IX.  Operations  on  the  Palate. — Operations  for  cleft  ixilate.— .Re 

moval  of  growths  of  the  palate, 317-325 

X.  Removal  of  the  Tongue, 325-340 

XI.  Operations  on  the   Tonsil.— Removal   of  new  growths  of  the 

tonsil, 340-344 

XII.  Operations  on  the  Air-passages  in  the  Neck. — Thyrotomy. — 
Laryngotomy.  —  Tracheotomy.  —  Tracheotomy  for  membranous 
laryngitis. — Tubage  of  the  larynx  as  a  substitute  for  tracheotomy 
in  membranous  laryngitis. — Otlier  indications  for  tracheotomy. — 
Foreign  bodies  in  the  bronchi. — Excision  of  the  larynx,  partial  and 
complete. — Partial  removal  of  the  larynx, 344-385 


CONTENTS.  11 

CHAP.  PAGES 

XIII.  Opekatioks  on  the  Thykoid  Gland. — Kemoval  of  the  thyroid, 

partial  and  complete, 385-407 

XIV.  Eemoval  of  large  deep-seated  Growths  in  the  Neck,        .  407-411 

XV.  Operations  on  the  QiIsophagus. — CEsophagotomy. — CEsophagos- 

tomy. — CEsophagectomy, 411-416 

XVI.  Operations   on   the   Spinal   Accessory   Nerve. — Division  or 

nerve-stretching, 417-419 

XVII.  Ligature  of  the  Arteries  of  the  Head  and  Neck. — Liga- 
ture of  the  temporal. — Ligature  of  the  facial. — Ligature  of  the 
occipital. — Ligature  of  the  lingual. — Ligature  of  the  common  car- 
otid.— Ligature  of  the  external  carotid. — Ligature  of  the  internal 
carotid. — Ligature  of  the  vertebral. — Ligature  of  the  subclavian. — 
Ligature  of  the  innominate. — Surgical  interference  in  aneurisms  of 
the  innominate  and  aorta, 419-498 


PAKT  III. 
OPERATIONS  ON  THE  THORAX 
I.  Removal  of  the  Breast 499-510 

11.  Paracentesis  and  Incision  of  Chest. — Empyema. — Resection  of 

ribs, 511-523 

III.  Drainage  of  Lung-Cavities, 523-527 


PART  IV. 
OPERATIONS  ON  THE  ABDOMEN. 

Ligature  of  Vessels. — Ligature  of  the  external  iliac. — Ligature 
of  the  common  iliac. — Ligature  of  the  internal  iliac. — Ligature  of 
the  gluteal. — Ligature  of  the  sciatic. — Ligature  of  the  abdominal 
aorta,        .........         ...  528-558 


12  CONTENTS. 

CHAP.  PAGE 

11.  Operations  on  Hernia. — Operations  for  strangulated  hernia. — 
Strangulated  femoral  hernia,  —  Strangulated  inguinal  hernia. — 
Strangulated  umbilical  hernia. — Strangulated  obturator  hernia. — 
Radical  cure  of  hernia. — Radical  cure  of  inguinal  hernia. — Radi- 
cal cure  of  femoral  hernia.— Radical  cure  of  umbilical  hernia,       .  558—590 

III.  CoLOTOMY. — Lumbar  or  posterior  colotomy. — Inguinal   or  anterior 

colotoray, 590-610 

IV.  Operations  on   the    Kidney. — Nephrotomy. — Nephro-lithotoray. 

— Nephrectoi^y. — Nephrorraphy,   .        ,         .         .        .        .         ,  610-645 

V.  Operations  on  the  Intestines. — Acute  intestinal  obstruction. — 
Exploration  of  abdomen  in  acute  intestinal  obstruction.— Enterot- 
omy.  —  Formation  of  artificial  anus  in  acute  intestinal  obstruc- 
tion.— Operative  treatment  of  suppurative  peritonitis. — Closure  of 
artificial  anus. — Enterectomy. — Colectomy, 645-666 

Vr.  Operative  Interference  in  Ctunshot  and  other  Injuries  of 

THE  Abdomen, 666-677 

Vll.  Operations  on  the  Stomach. — Gastrostomy. — Gastrotomy. — Digi- 
tal dilatation  of  the  orifices  of  the  stomach. — Dilatation  of  the  py- 
lorus.— Dilatation  of  the  cardiac  orifice. — Excision  of  pylorus. — 
Gastro-enterostomy.  —  Duodenostomy. — Jejunostomy. — Treatment 
of  gastric  cancer  by  the  use  of  the  curette, 677-700 

VIII.  Excision  of  the  Spleen, 700-702 

IX.  Operations  on  the  Liver  and  Gall- Bladder. — Operations  for 
hydatids. — Hepatic  abscess. — Hepatotomy. — Tapping  and  incising 
the  gall-bladder. — Cholecystotomy. — Removal  of  biliary  calculi. — 
Cholecystectomy, 702-713 

X.  Operations    on   the   Ovary.  —  Ovariotomy.  —  Removal    of  the 

uterine  appendages,        .........     713-725 

XI.  Operations  on  the  Uterus. — Removal  of  myomata  by  abdominal 
section. — Removal  of  cancerous  uterus  by  abdominal  section. — Re- 
moval of  a  cancerous  uterus  per  vaginara. — Caesarian  section,         .  725-734 

XII.  Operations  ON  the  Bladder. — Removal  of  growths  of  the  blad- 
der.— Lateral  lithotomy. — Supra-pubic  lithotomy. — Median  litho- 
tomy.— Lithotrity. — Litholapaxy. — Litholapaxy  in  male  children. 
— Treatment  of  stone  in  the  bladder  in  the  female.— Cystotomy. — 
Ruptured  bladder. —Puncture  of  the  bladder,  .         .        .         .735-781 

XIII.  Operations  on  the  Urethra  and  PENis.—Ruptured  urethra. — 
External  urethrotomy. — Choice  of  operation  for  the  relief  of  stric- 
ture-retention.— Internal  urethrotomy. — Ectopia  vesicae.  —  Hypo- 
spadias.— Epispadias. — Circumcision. — Amputation  of  the  penis,  .  781-806 


CONTENTS.  1 3 

CHAP.  PAGES 

XIV.  Operations  ON  the  Scrotum  and  Testicle. — Eadical  cure  of  hy- 
drocele.— Varicocele.  — Castration, 807-819 

XV.  Operations  on  the  Anus  and  Rectum. — Fistula. — Hfemorrhoids. 
— Fissure.  —  Prolapsus.  —  Excision  of  the  rectum. — Imperforate 
anus. — Imperfectly  developed  rectum, 819-838 

XVI.  Ruptured  Perineum, 838-843 


PART   V. 

OPERATIONS  ON  THE  LOWER  EXTREMITY. 

I.  Operations  on  the  Hip-Joint. — Amputation  at  the   hip-joint. — 

Excision  of  the  hip-joint, 844-866 

II.  Operations  on  the  Thigh. — Ligature  of  the  common  femoral. — 
Ligature  of  the  superficial  femoral  in  Scarpa's  triangle. — Ligature 
of  the  superficial  femoral  in  Hunter's  canal  — Puncture  and  stab 
wound  in  mid-thigh. — Amputation  through  the  thigh. — Amputa- 
tion immediately  above  the  knee-joint. — Removal  of  exostosis  from 
near   the  adductor  tubercle. — Ununited  fracture  of  the  femur,       .  866-891 

III.  Operations  Involving  the  Knee-Joint. — Amputation  through 
the  knee-joint. — Excision  of  the  knee-joint. — Arthrectomy  of  the 
knee-joint. — Wiring  the  patella. — Removal  of  loose  cartilages  from 
the  knee-joint, 891-917 

IV.  Operations  on  the  Popliteal  Space. — Ligature  of  the  popliteal 

artery, 917-920 

V.  Operations  on  the  Leg. — Ligature  of  posterior  tibial. — Ligature 
of  anterior  tibial. — Ligature  of  peroneal  artery. — Amputation  of 
leg. — Operation  for  necrosis. — Treatment  of  compound  fracture,     .  920-937 

VI.  Operations  on  the  Foot.  —  Ligature  of  the  dorsalis  pedis. — 
Syme's  amputation. — Roux's  amputation. — Pirogoff's  amputation. 
Sub-astragaloid  amputation. — Excision  of  the  ankle. — Excision  of 
tarsal  joints. — Excision  of  astragalus. — Excision  of  os  calcis. — 
Operations  for  more  complete  tarsectomy. — Removal  of  tarsal  bones 
for  inveterate  talipes.  —  Chopart's  amputation.  —  Amputation 
through  the  tarso-metatarsal  joints. — Amputation  of  the  toes,  .  938-963 

VII.  Osteotomy. — Osteotomy  of  the  femur  for  ankylosis  of  the  hip-joint, 
— For  genu  valgum. — Osteotomy  of  the  tibia. — Osteotomy  for  dis- 
placement of  the  great  toe  in  bunion, 964-973 


14  CONTENTS. 


CHAP.  PAGES 

VIII.  Tenotojiy. — Tenotomy  of  the  tendons  about  the  foot. — Syndesmotomy. 

Tenotomy  of  hamstring  tendons. — Tenotomy  of  sterno-mastoid,     .  973-978 

IX.  Opeeations  on  Nerves. — Nerve  suture. — Nerve  stretching,     .        .  978-984 


PART  VI. 


Operations  on  the  Vertebral  Canai,. — Spina  bifida. — Trephin- 
ing the  vertebral  canal,     985-987 


APPENDIX. 

Tapping  and  Incising  the  Pericardium,      .        .        .        .        .  988-990 

INDEX  OF  NAMES, 991-995 

GENERAL  INDEX, 996-1006 


ERRATA. 


Page  110,  33d  line,  transpose  words  "latter"  and  "former." 

"  119,  7th  ]ine,/o?-  "  thumb  "  read  "  forefinger." 

'•  1 50,  1 2th  line,  for  ''  of  "  read  "  oK" 

"  178,  8th  line, /or  "  external  auditory  meatus  "  read  "  external  angular  process." 

"  195,  9th  line,  omit  "where." 

"  210,  7th  line,  for  "  roof"  read  "  root." 

"  212,  14th  line, /or  "fissure"  read  "  meatus." 

"  272,  15th  line, /or  "  molar"  read  "  malar." 

"  295,  39th  line, /or  "  horizontal"  read  "  vertical.^' 

"  336,  1st  line, /or  "on  the  hyoglossus  "  'read  "behind  or  under  the  hyoglossus." 

"  371,  24th  line,/o'-  "  suppurative"  read  "suffocative." 

"  402,  19th  line, /or  "Fig.  86"  read " Fig. 85." 

"  403,  22d  line, /or  "vascular"  read  "  evascular." 

"  405,  12th  line, /or  "excision  "  read  "incision." 

"  461,  22d  line, /or  "  against"  read  "  below." 

"  498,  24th  line,  for  "  Dr.  McCall "  read  "  Dr.  McCall  Anderson." 

"  545,  26th  line,  after  "  first  tied  "  insert  "  for  aneurism." 

"  582,  22d  line,  for  "  cord  "  read  "  sac." 

"  599,  13th  line, /or  "  face"  read  "  back." 

"  607,  40th  line, /or  "  Brunton  "  read  "  Brinton." 

"  618,  in  "  DiflBculties  in  Nephro-Lithotomy  "  the  headings  "  3, 4,  5,  6,  7,  8,  9, 10," 

should  be  "4,  5,  6,  7,  8,  9,  10,  11  " 

"  629,  5th  line,  for  "  e  "  read  "  vi." 

"  651,  24th  line, /or  " peri-typhilitis "  read  "perityphlitis." 

"  929,  Fig.  177.     The  knife  should  have  been  passed  from  the  opposite  side. 


PART  I. 


OPERATIONS   ON   THE   UPPER   EXTREMITY. 


CHAPTER  I. 


OPERATIONS  ON  THE  HAND. 

AMPUTATION  OF  FINGERS. 

Practical  Anatomical  Points. — I.  Position  of  Joints  (Fig. 
1). — This  has  to  be  remembered — '.a)  in  front,  (/3)  behind. 

(«)  In  Front. — Three  sets  of  creases  correspond  here,  though  not 
exactly,  to  the  joints.  Of  these,  the  lowest  crease  is  just  above  the 
joint ;  the  middle  is  opposite  to  the  inter-phalangeal  joint ;  the 
highest,  4  inch  below  the  metacarpo-phalangeal  joint. 

{[i)  Behina. — It  is  to  be  remembered  here  (1)  that  in  each  case 
it  is  the  upper  bone  which  forms  the  prominence — viz.,  the  knuckle 


Fig.  1. 


is  formed  by  the  head  of  the  metacarpal  bone,  the  inter-phalangeal 
prominence  by  the  head  of  the  first  phalanx,  and  the  distal  one  by 
the  head  of  the  second  ;  (2)  that  the  joint  in  each  case  lies  below* 
the  prominence,  the  distal  joint  being  -^  inch,  the  inter-phalangeal 
i  inch,  and  the  metacarpo-phalangeal  joint  i  inch  below. 

II.  Shape  of  Joints. — In  the  distal  and  the  inter-phalangeal  the 
joint  is  concave  from  side  to  side,  and  presents  a  concavity  towards 

*  The  terms  "above"  and  "  below"  mean  nearer  and  farther  from  the  trunk. 


18  OPERATIOKS    ON    THE    UPPER    EXTREMITY. 

the  tii)s ;  in  tlie  metacarpo-i^halangeal  joint,  on  the  other  hand,  the 
convexity  is  towards  the  finger-tips.* 

III.  The  Theca. — This  fibrous  tunnel  running  up  to  the  bases 
of  the  distal  phalanges  gapes  widely  after  section.  From  its  prone- 
ness  to  conduct  upwards  spreading  sepsis,  care  should  be  taken  to 
keep  even  such  a  small  amputation  as  that  of  a  finger  strictly  sweet, 
and,  in  amputating  through  damaged  parts,  the  flaps  should  not  be 
too  closely  united  with  sutures. 

Operations  for  Amputation  of  Fingers.— As  a  fixed  rule 

is  rarely  available,  several  should  be  practiced,  including  among 
them  the  following  four,  viz. : 

1.  Long  jDalmar  flap  (Figs.  2,  3,  and  4). 

2.  Long  dorsal  flap. 

3.  Two  equal  antero-posterior  flaps. 

4.  Two  lateral  flaps  (Fig.  5). 

Of  these,  the  palmar  flap  is  usually  the  one  made  use  of  Though, 
as  the  hands  are  by  far  most  frequently  placed  in  the  prone  posi- 
tion, a  dorsal  flap  falls  more  easily  into  place,  and  gives  a  more 
concealed  scar,  a  palmar  flap  has  the  greater  advantages  of  not 
being  pressed  upon  when  anything  is  held  in  the  hand,  of  pos- 
sessing finer  sensitiveness  in  touch,  and,  furthermore,  of  being 
available  even  in  the  last  phalanx,  where,  from  the  presence  of  the 
nail,  a  dorsal  flap  is  not  obtainable  (Fig.  2). 

Amputation  of  Distal  Phalanx  by  Palmar  Flap  (Fig. 

2). — First  Method.— The  hand  being  pronated,  a  strip  of  lint 
wound  round  the  phalanx  to  give  a  firm  grip,t  and  the  adjacent 
fingers  held  aside  with  •  tapes,  the  surgeon,  having  placed  his  left 
forefinger  just  below  and  behind  the  joint,  and  flexed  the  phalanx 
strongly  with  his  thumb,  cuts,;};  with  a  slightly  semilunar  sweep, 
straight  into  the  joint.  To  effect  this  neatly,  the  convexity  of  the 
sweep  should  pass  y^2^inch  below  the  prominence  or  angle  produced 
by  flexion,  the  sweep  being  made  by  laying  on  the  whole  edge  of 
the  knife,  while  with  the  point,  as  this  incision  begins  and  ends, 
the  lateral  ligaments  are  partly  cut.  The  joint  being  thus  freely 
opened,  the  knife  is  insinuated  behind  the  base  of  the  phalanx  (a 
step  which  is  facilitated  by  depressing  and  pulling  on  the  phalanx), 
and  then,  being  kept  close  to,  and  parallel  with,  the  bone,  cuts, 

*  Tliis  is  shown  in  Fig.  1.  In  the  lower  two  joints,  a  convexity,  and  not  a  con- 
cavity, appears  to  exist  towards  the  tips.  This  is  due  to  one  of  the  small  lateral 
condyles,  which  are  present  on  the  digital  extremity  of  each  phalanx,  being  shown, 
and  thus  disguising  the  median  concavity. 

f  In  the  drawing  this  is  left  out  for  the  sake  of  distinctness. 

X  The  knife  in  all  these  finger  amputations  should  be  narrow,  slender  short,  and 
strong. 


AMPUTATION   OF    FINGERS. 


19 


Fig.  2.t 


with  a  steady,  sawing  movement,  a  fiap  well  roiinded  at  its  ex- 
tremity, about  two-thirds  in  length  of  the  pulp  of  the  finger.* 

Second  Method. — The  hand  being  supinated,  the  finger  to  be 
operated  on  extended,  and  the  others  flexed  out  of  the  way,  a  pal- 
mar flap  is  cut  by  transfixion,  the 
knife  being  entered  just  below  the 
palmar  crease,  the  joint  being  then 
opened  from  the  dorsum  as  before, 
and  the  phalanx  lastly  disarticu- 
lated. 

Third  Method.— If  the  sur- 
geon has  no  narrow  knife  by  him, 
he  may  modify  the  last  method  by 
cutting  his  palmar  flap  first,  but 
from  without  iuAvards ;  he  then 
opens  the  joint  from  the  dorsum, 
and  disarticulates. 

As  a  rule,  no  vessels  require  liga- 
ture. Any  tendon  that  is  ragged 
should  be  cut  square. 

Difficulties  and  Mistakes  in  Amputation  of  Distal  Pha- 
lanx.— The  flap  may,  of  course,  be  made  too  short;  it  is  often 
made  too  pointed.  If  the  phalanx  be  not  sufficiently  flexed,  or  if 
the  site  of  the  joint  be  forgotten,  the  latter  will  not  be  readily 
opened,  the  knife  sawing  against  the  second  phalanx.  It  is  often 
difficult  to  pass  the  knife  easily  behind  the  base  of  the  phalanx, 
especially  in  cases  where  the  blade  is  too  broad,  or  Avhere,  as  may 
happen  in  well-developed  hands,  the  circumference  of  the  base  of 
the  phalanx  is  strongly  tuberculated.  And  if  there  be  any  consid- 
erable hitch  in  passing  the  knife  behind  the  phalanx,  the  base  of 
the  flap  is  very  likely  to  be  jagged. 

Amputation  of  Second  Phalanx.— This,  as  a  rule,  should 

be  performed  through  the  phalanx,  and,  wherever  this  is  possible, 
beyond  its  centre,  so  as  to  leave  the  upper  half  or  third  of  the  pha- 
lanx, and  thus  ensure  some  attachment  of  the  flexor  being  pre- 
served. 

While  the  rule  not  to  amputate  a  finger  at  the  joint  between  the 
first  and  second  phalanges,  and  a  fortiori  through  the  first  phalanx, 
is  a  sound  one,  as  there  is  a  risk  of  leaving  a  stump  stiff  and  inca- 
pable of  flexion,  there  is  no  doubt  whatever  that  at  times  the  above 
amputation  has  been  followed  by  the  flexor  tendon  taking  on  a 

*  If  the  flap  is  insufficient,  the  head  of  the  second  phalanx  will,  of  course,  be 
removed. 

f  The  palmar  flap  here  is  made  somewhat  too  short,  sharp,  and  wedge-shaped. 


20  OPERATIONS   ON    THE    UPPER    EXTREMITY. 

fresh  and  sufficiently  firm  adhesion,  and  so  leaving  a  longer  and 
withal  a  mobile  stump. 

In  the  following  special  cases  the  whole  or  part  of  the  first  pha- 
lanx m<iy  be  left,  and  in  all  of  them  the  severed  flexor  tendons 
should  be  carefully  stitched  with  carbolized  silk  to  the  cut  theca 
and  periosteum,  or  into  the  flaps  themselves  before  adjusting  these. 

1.  In  the  case  of  the  index  finger  the  proximal  phalanx  will  be 
a  useful  opponent  to  the  thumb,  as  in  holding  a  pen. 

2.  In  the  case  of  the  little  finger,  leaving  the  proximal  phalanx 
will  give  greater  symmetry  to  the  hand  when  this  is  flexed,  and  it 
should  accordingly  be  left,  if  the  patient  desire  it. 

3.  In  cases  of  amputation  of  all  the  fingers,  the  proximal  pha- 
lanx of  one  should,  if  possible,  always  be  left  to  oppose  to  the 
thumb. 

Fig.  3. 


Amputation  through  inter-phalangeal  joint  by  long  palmar  flap,  the  joint 
being  opened  first.    (Fergusson.) 

4.  In  the  case  of  a  patient  who  insists  on  having  the  proximal 
phalanx  left,  after  the  risk  of  stiffness  has  been  explained  to  him, 
the  more  care  is  taken  to  fix  the  severed  flexors  to  the  theca,  the 
more  quickly  the  stump  heals,  and  tlie  younger  the  patient,  the 
greater  will  be  the  movement  gained. 

Dr.  Tifi"any,  of  Baltimore  (Trans.  Amer.  Surg,  ^s-soc,  vol.  ii.  p. 
826),  says  that  he  has  been  in  the  habit  "  for  a  number  of  years  "  of 
passing  the  stitches  which  unite  the  skin  through  the  tendons  and 
their  sheaths  in  cases  of  amputation  at  the  joint  between  first  and 
second  phalanges.     "I  have  never  failed,  as  far  as  I  can  remember, 


AMPUTATION    OF    FINGERS.  21 

to  secure  quite  as  good  movement  as  if  nature  had  originally  made 
an  attachment  there  for  these  tendons." 

Amputation  through  Middle  Phalanx. 

(1)  By  a  Long  Palmar  Flap  (Figs.  3  and  4),  or  by  Dorso- 
palmar  Flaps,  the  palmar  Haps  being  the  longer  (Fig.  5). 

By  Dorso-palmar  Flaps. — The  surgeon,  marking  with  his  left 
fore-finger  and  thumb*  where  he  intends  to  divide  the  bone,  cuts 
between  these  points  a  short  well-rounded  dorsal  flap  of  skin ;  he 
then  sends  his  knife  across  below  the  bone,  making  it  enter  and 
emerge  at  the  base  of  the  first  flap,  and  cuts  a  jjalmar  flap  about 
i  inch  in  length,  and  not  pointed.  The  flaps  are  then  retracted, 
the  bone  cleared  with  a  circular  sweep  of  the  knife,  and  divided  as 
above. 

By  Lateral  Flaps  (Fig.  5). — The  site  where  the  bone  is  to  be 
sawn  being  marked  by  the  left  fore-finger  and  thumb  placed  on  the 
dorsal  and  palmar  aspect  of  the  finger  at  this  level,  the  surgeon, 
looking  over  the  finger,  enters  his  knife  in  the  centre  of  the  palmar 

Fig.  4. 


Amputation  through  second  phalanx  by  long  palmar  flap,  this  being  made 
first  by  transfixion.    (Fergusson.) 

aspect,  and  carries  it,  cutting  an  oval  flap,  about  *  inch  in  length, 
to  a  corresponding  point  on  the  centre  of  the  dorsum,  and  then 
from  this  point  down  again  over  the  side  of  the  finger  nearest  to 
him,  to  the  point  where  the  knife  was  first  entered.  The  flaps 
being  dissected  up  as  thick  as  possible,  and  the  remaining  soft  parts 
severed  with  a  circular  sweep,  the  bone  is  divided  with  saw  or 
bone-forceps.  If  necessary,  one  fla])  can,  of  course,  be  cut  longer 
than  the  other.  In  using  the  bone-forceps  the  flat  or  convex  sur- 
face is  always  to  be  applied  towards  the  trunk ;  if  this  precaution  is 

*  These  are  left  out  in  the  drawings,  for  the  sake  of  distinctness. 


22 


OPERATIONS   ON    THE    UPPER    EXTREMITY. 


taken,  and  the  bone  severed  quickly,  the  section  will  be  clean,  and 
not  crushed. 

Amputation  of  Finger,  e  g.,  Second  or  Third,  at  Meta- 

Carpo-phalangeal  Joint  (Fig.  6}.— This,  the  most  frequently 
performed  amputation  on  the  hand,  should  be  practiced  frequently. 
It  is  best  performed  by  the  modified  oval  method,  the  en  raquette 
of  Malgaigne,  or  by  lateral  flaps. 

The  hand  being  pronated,  the  radial  and  ulnar  arteries  com- 
manded by  an  Esmarch's  bandage  above    the    wrist,  some  lint 


Fig.  F,. 


In  the  second  finger,  amputation  through  the  second  phalanx  by  lateral  flaps  is  shown. 
The  bone  has  been  divided  below  the  insertion  of  the  flexor  sublimis  ;  if  there  were  any 
doubt  about  this,  the  tendon  could  be  stitched  to  the  theca  and  flaps,  as  advised  above.  In 
the  index  finger,  amputation  through  the  second  phalanx  by  short  dorsal  and  long  palmar 
flaps  is  given.  The  left  finger  and  the  thumb  of  the  surgeon,  which  would  mark  the  base 
of  the  flaps,  are  left  out  for  the  sake  of  distinctness.  The  flaps  for  amputation  of  the  index 
finger  at  the  metacarpo-phalangeal  joint  are  also  shown,  the  straight  part  of  the  incision  be- 
ing placed  rather  to  the  radial  side  of  the  head  of  the  metacarpal  bone. 

In  the  thumb,  the  flaps  for  amputation  at  the  carpo-metacarpal  joint  are  indicated.  The 
two  **  show  where  the  radial  artery  may  be  wounded,  near  the  joint,  and  in  the  interosseous 
space,  in  this  amputation. 

Ligature  of  the  radial  artery  at  the  back  of  the  wrist  is  also  represented.  The  radial  vein 
crosses  the  wound  from  angle  to  angle.  The  artery,  with  the  ligature  under  it,  is  shown  be- 
tween the  extensor  ossis  metacarpi  and  extensor  primi  internodii  in  the  lower  angle,  and  the 
extensor  secundi  internodii  in  the  upper  angle  of  the  wound. 

wrapped  round  the  damaged  finger,  and  the  adjacent  ones  held 
aside  by  tapes,  the  point  of  the  knife  is  entered  f  inch  above  the 
head  of  the  metacarpal  bone,  sunk  down  to  the  bone  itself,  and  then 
carried  down  in  the  middle  line  till  it  gets  well  on  to  the  base  of  the 
phalanx;  then,  diverging  to  one  side,  the  knife  is  carried  obliquely 
below  the  web  across  the  palmar  aspect  of  the  first  phalanx  below 
the  palm,  and  then  around  the  other  side  of  the  phalanx  (also  be- 
low the  web)  so  as  to  join  the  straight  part  of  the  incision  which 
lies  over  the  head  of  the  metacarpal  bone.     In  practice,  especially 


AMPUTATION    OF    FINGERS. 


23 


Fig.  6. 


in  the  country,  where  an  anaesthetic  is  not  always  easily  available, 
it  is  much  preferable,  because  quicker,  to  make  two  separate  inci- 
sions, each  beginning  f  inch  above  the  head  of  the  metacarpal  bone, 
and  meeting  again  on  the  centre  of  the 
base  of  the  palmar  aspect  of  the  first  pha- 
lanx, well  below  the  palm,  instead  of 
carrying  the  knife  continuously  round 
the  finger.  This  method  is  not  only 
quicker,*  but  it  does  not  leave,  as  in  the 
first  method,  a  small  tongue  of  tissues  on 
the  palmar  aspect,  which  is  a  little  diffi- 
cult to  adjust  satisfactorily,  and  behind 
which  discharges  tend  to  collect. 

In  either  case  the  knife  should  be  used 
boldly,  the  extensor  tendon  severed  in  the 
first  incision  over  the  head  of  the  meta- 
carpal bone,  and  the  soft  parts  at  the  sides 
cut  to  the  bone.  Then  one  lip  of  cut  tissue 
being  taken  up  with  finger  and  thumb,  the 
flaps  are  dissected  up  as  thickly  as  possi- 
ble, tendons  cut  clean  and  square,  the 
lateral  ligaments  severed,  and  the  joint 
opened  by  remembering  its  site  well  be- 
low the  projecting  knuckle  (p.  17,  Fig.  1). 
Disarticulation  will  be  facilitated  by  tAvist- 

ing  the  finger,  first  to  one  side,  and  then  to  the  other,  so  as  to  render 
tight  the  parts  which  remain  to  be  cut. 

Where  strength  has  to  be  considered  rather  than  appearance,  the 
head  of  the  metacarpal  bone  should  be  left,  as  the  transverse  liga- 
ment is  thus  less  interfered  with,  and  the  hand  less  weakened.  But 
where  appearance  is  the  most  important  thing,  and  the  mutilation 
is  to  be  hidden  as  much  as  possible  by  the  approximation  of  the 
fingers,  the  head  of  the  bone  should  be  removed  by  a  narrow-bladed 
saw  or  by  bone-forceps.f  In  either  case  the  section  should  be  made 
obliquely  from  above  downwards  and  from  behind  forwards,  so  as 
to  remove  more  on  the  dorsal  than  the  palmar  aspect.  In  such 
cases,  after  a  little  practice,  it  is  not  necessary  to  perform  disarticu- 
lation, the  metacarpal  bone  being  severed  after  dissecting  up  the 
flaps  to  the  proper  level.  Here,  too,  care  must  be  scrupulously 
taken  not  to  interfere  with  the  tissues  in  the  palm. 

After  removal  of  the  finger  and  the  Esm arch's  bandage,  one  or 


Incisions  for  amputation  at 
metacarpo-phalangeal  joint.  If 
the  metacarpal  bone  requires 
removal  as  well,  the  apex  of 
the  incision  would  be  pro- 
longed upwards.      (Fergusson  j 


*  Because  it  .ivoids  the  hitch  usually  met  with  in  carrying  the  knife  aronnd  the 
base  of  one  finger  between  others. 

f  With  the  precautions  already  given  at  p.  22. 


24  OPERATIONS   ON    THE    UPPER    EXTREMITY. 

more  digital  vessels  will  require  ligature,  lying  rather  deeply  oppo- 
site the  web  of  the  finger.* 

In  the  case  of  the  index  (Fig.  5)  or  little  finger,  the  straight  part 
of  the  oval  incision  should  be  placed  to  the  radial  or  ulnar  side  of 
the  metacarpal  bone  respectively,  rather  than  in  the  dorsal  mid- 
line, as,  in  the  former  case,  the  line  of  incision  will  be  concealed 
between  the  thumb  and  second  finger,  and,  in  the  latter,  be  less 
visible  in  the  ordinary  pronated  position  of  the  hand.  In  these 
cases  the  bone-forceps  should  be  applied  obliquely  from  without 
inwards  and  from  within  outwards  respectively,  so  as  to  leave  no 
projecting  bone  on  the  radial  or  ulnar  aspect  of  the  hand,  and,  in 
the  former  case,  to  allow  of  the  thumb  being  readily  approximated 
to  the  adjacent  finger. 

It  may  be  worth  while  to  add  one  hint  with  regard  to  the  after- 
treatment,  and  that  is,  not  to  bandage  the  adjacent  fingers  too 
closely  or  too  long  together,  otherwise  a  tendency  to  cross  at  their 
points  will  be  noticed  later  on. 

Conditions  requiring  Amputation  of  Fingers  usually  at 
the  Metacarpo-phalangeal  Joint: 

1.  Smash  (machinery,  gunshot,  etc.). 

2.  Results  of  thecal  trouble  at  an  earlier  and  later  period. f 

3.  "  Strumous  dactylitis,"  when  it  does  not  yield  to  treatment ; 
when  it  interferes  with  the  general  health,  especially  in  a  patient  no 
longer  young ;  and  Avhen  it  is  likely  to  end  in  a  useless  finger. 

4.  Enchondromata,  if  multiple  and  crippling  the  finger;  if  single 
and  small,  an  attempt  should  be  made  to  save  the  finger  by  shaving 
off  the  growth  and  gouging  its  base,  the  soft  parts  being  carefully 
retracted  and  protected.     (See  the  case  referred  to  below,  p.  27.) 

5.  Supernumerary  fingers. | 

6.  Gangrene,  or  frostbite. 

*  Care  should  be  taken  to  secure  these  vessels,  especially  where  they  are  enlarged 
in  any  inflammatory  condition,  otherwise  profuse  bleeding  may  take  place  a  few 
hours  after  the  operation. 

f  This  includes  not  only  stiff  and  useless  fingers,  but  also  those  crippled  with 
peripheral  neuralgia  from  implication  of  digital  nerves  in  the  indurated  tissues. 
See  a  paper  by  Mr.  Callender,  Clin.  Soc.  Trani^.,  vol.  ix.  p.  104;  also  a  case  under 
Prof.  Syme,  in  which  burning  sensation  and  distressing  pain  followed  a  wound  of 
a  digital  nerve,  onl}»  remedied  by  amputation  at  the  .raetacarpo-phalangeal  joint; 
Annandale,  Diseases  of  Fingers  and  Toes,  p.  203. 

J  If  a  mother  object  strongly  to  any  cutting  operation  in  the  removal  of  a  super- 
numerary finger  in  an  infant  newly  born,  a  suggestion  of  Sir  W.  Fergusson's  {Pract. 
Surg  ,  p.  311)  may  be  made  use  of — to  strangle  it  either  by  transfixion  and  double 
ligature,  or  by  giving  the  flexible  root  a  twist  round  once,  laying  the  finger  on  the 
back  of  the  hand  and  securing  it  there. 


y^ 


AMPUTATION    OF    THUMB.  25 


AMPUTATION  OF  THUMB. 
Amputations  of  Phalanges  of  Thumb.— Very  little  need 

be  said  about  these,  as  they  are  very  rarely  performed.  Owing  to 
its  numerous  muscles,  the  thumb  is  extremely  mobile,  and  thus 
escapes  injury.  Owing  to  its  abundant  vascular  supply,  trimming 
of  the  soft  parts  after  an  injury  will  generally  leave  more  of  the 
thumb  to  oppose  to  the  fingers  than  any  set  operation. 

In  cases  of  necrosis  after  wliitlow,  I  have  twice  removed  both 
phalanges,  the  soft  parts  consolidating  usefully.*  For  further  re- 
marks on  preserving  the  thumb,  see  Excision  of  Thumb,  p.  27. 

Operation, — Amputation  of  the  phalanges  of  the  thumb  may 
be  performed,  in  the  case  of  the  distal  one,  by  a  long  palmar  flap, 
as  in  the  case  of  a  finger  (Figs.  2,  3,  4) ;  in  the  case  of  the  first  pha- 
lanx, by  antero-posterior,  lateral,  or  a  modification  of  the  oval 
method.  In  any  case  the  incisions  should  be  carried  well  on  to  the 
phalanx  to  ensure  sufficient  flaps  to  cover  the  head  of  the  meta- 
carpal bone,  together  with  the  sesamoid  bones,  which  should  never 
be  removed. 

The  line  of  the  metacarpo-phakingeal  joint  is  very  nearly  trans- 
verse, and  lies  just  in  front  of  the  knuckle. 

After  amputation  of  either  phalanx,  the  severed  end  of  the  long 
flexor  should  be  carefully  stitched  into  the  angle  of  the  flaps  and  to 
the  theca  and  periosteum. 

Amputation  of  Thumb   at   Carpo-metacarpal  Joint 

(Figs.  5  and  7). 

Indications. — This  operation  is  rarely  called  for  on  tlie  living 
subject. t  Gunshot  injuries,  enchondromata  of  phalanges  and  me- 
tacarpal bone  (see  below,  p.  27),  epithelioma  of  a  scar,  melanotic 
sarcoma,  occasionally  call  for  it. 

Operation. — The  position  of  the  joint  between  the  trapezium 
and  metacarpal  bone,  its  shape,  with  two  saddle-like  articular  sur- 
faces fitting  into  each  other  "  by  reciprocal  reception,"  and  the  po- 
sition of  the  radial  artery  passing  over  the  back  of  the  styloid  pro- 
cess just  above  this  joint  (Fig.  5),  and  again,  when  perforating  the 
first  interosseous  space,  lying  close  to  the  metacarpal  bone,  must  be 
remembered. 

The  operation  is  usually  performed  by  the  oval  method. 

An  Esmarch's  bandage  being  api^lied  above  the  wrist,  the  hand 
held  midway  between  pronation  and  supination,   and  the  thumb 

*  This  is  strongly  indicated  in  those  cases  where  it  is  especially  important  to- 
leave  the  thumb  long  for  holding  a  pen  or  delicate  instrument, 
t  It  is  not  unfreqiiently  used  as  an  examination  test. 


26 


OPERATIONS    OX   THE    UPPER    EXTREMITY. 


Fig.  7. 


held  rather  over-extended  so  as  to  relax  the  i^arts,  the  surgeon 
enters  the  point  of  a  strong  narrow  scalpel  or 
histoury  just  above  the  bony  tubercle,  which 
usually  marks  the  insertion  of  the  extensor 
ossis  metacarpi  pollicis  into  the  base  of  the 
metacarpal  bone,  and  carries  it  along  the 
dorsum  of  this  none  as  far  as  the  base  of  the 
first  phalanx,  where  it  passes  (in  the  case 
of  the  left  thumb)  obliquely  to  the  ulnar 
side  above  the  Aveb,  and  then  around  the 
palmar  aspect  of  the  phalanx,  along  the 
radial  side,  to  join  the  dorsal  incision  again. 
Taking  up  first  one  edge  of  the  incision  and 
then  the  other,  the  surgeon  dissects  up  the 
soft  parts  from  the  bone,  keeping  the  knife- 
point very  closely  to  this,  especially  on  the 
inner  side.  The  extensor  tendons  and  the 
short  muscles  of  the  thumb  being  severed, 
the  joint  between  the  trapezium  and  meta- 
carpal bone  is  felt  for  and  opened  by  putting 
the  tissues  here  on  the  stretch  by  twisting 
the  metacarpal  bone  in  diff*erent  directions. 
Amputation  of  Thumb  at  Carpo- 
metacarpal Joint  by  Transfixion  (Fig. 
7). — The  hand  being  held  as  before,  and  the 
parts  relaxed  by  slightly  adducting  the  thumb,  an  incision  is  made 
(in  the  case  of  the  left  thumb)  from  the  base  of  the  metacarpal  bone 
rather  to  its  palmar  aspect,  along  its  dorsum,  and  then  obliquely 
to  the  ulnar  side  of  the  base  of  the  first  phalanx  ;  the  knife,  a  long 
narrow  bistoury,  is  then  pushed  from  this  point  at  the  junction  of 
the  web  with  the  thumb,  across  the  palmar  aspect  of  the  thumb,  to 
the  point  where  the  incision  started,  over  the  carpo-metacarpal 
joint.  By  cutting  outwards,  along  the  line  indicated  in  Fig.  7,  a 
flap  is  formed  of  the  tissues  in  the  ball  of  the  thumb,  the  knife 
being  kept  close  to  the  bone  at  first,  but  used  more  lightly  and  kept 
more  superficial  afterwards,  as  it  comes  out  through  the  skin  over 
the  sesamoid  bones  and  base  of  the  first  phalanx,  to  avoid  being 
locked  here.  This  flap  being  held  back,  the  metacarpal  bone  is 
dissected  out  by  keeping  the  knife  close  to  it,  the  joint  opened,  and 
the  thumb  removed  as  before. 

On  the  right  side,  it  is  better  to  cut  the  palmar  flap  by  transfix- 
ion first,  making  it  enter  and  emerge  just  as  above  given.  The  blade 
of  the  knife  is  then  drawn  from  the  base  of  the  first  phalanx  ob- 
liquely across  the  dorsum  of  the  metacarpal  bone,  from   one  ex- 


EXCISION    OF    THUMB    AND    FINGEES.  27 

tremity  of  the  transfixion  incision  to  the  other.     The  operation  is 
then  completed  as  before. 

EXCISION  OP  THUMB  AND  FINQERS. 

Removal  of  Phalanges. — Owing  to  the  exceeding  value  of 
the  thumb,  a  phalanx  should  always  be  preserved  if  possible,  not 
only  in  wdiitlow-necrosis,  but  in  the  case  of  the  first  or  proximal 
phalanx,  w^hen  it  is  the  seat  of  enchondroma.  By  this,  not  only  is 
appearance  saved  by  the  lessened  shortening,  but  the  use  of  the 
long  flexor,  in  particular,  is  preserved.  Thus,  Mr.  Royes  Bell 
(Lancet,  1872,  vol.  ii.  p.  846)  published  a  case  in  which  he  excised 
the  proximal  phalanx  in  a  woman,  aged  nineteen,  for  a  huge 
enchondroma  of  sixteen  years'  growth,  the  joints  being  movable. 
The  phalanx  w^as  excised  by  two  lanated  incisions  over  the  tumor, 
the  knife  kept  close  to  the  bone,  and  the  joints  opened.  No 
tendons  were  cut.  Eighteen  months  later  the  condition  of  the 
thumb  w^as  excellent,  both  for  all  general  movements  and  for 
writing. 

Removal  of  Metacarpal  Bone.— This  should  always  be  ex- 
cised wherever  possible,  in  preference  to  sacrificing  a  part  of  such 
incalculable  value  as  the  thumb.  Sir  W.  Fergusson  {Pract.  Surg., 
p.  322),  in  speaking  of  this  operation,  says  that  he  saw  it  once  per- 
formed, and,  though  the  organ  was  far  from  strong,  the  patient 
could  use  a  needle  with  tolerable  facility  not  long  after,  and  he 
further  remarks  that  the  comparative  shortness  of  the  bone  re- 
moved, and  the  firm  cusnfcn  of  soft  parts  that  remains  after  its 
excision,  wall  make  the  remaining  part  useful. 

In  removing  the  metacarpal  bone,  a  straight  incision,  which 
reaches  i  inch  beyond  each  extremity  of  the  bone,  having  been 
made  along  the  dorsum,  the  tendons  are  drawn  aside;  the  distal 
end  and  joint  are  next  cleared  and  opened,  wdien  the  bone  can  be 
used  as  a  lever  whilst  it  is  freed  from  the  soft  parts  on  the  palmar 
aspect  and  then  disarticulated. 

The  radial  artery  must  be  remembered  both  on  the  ulnar  side 
of  the  metacarpal  bone  and  by  the  carpo-metacarpal  joint  (Fig.  5). 

Excision  of  Metacarpo-phalangeal  Joint.— This  may  be 

very  occasionally  required  in  those  cases  where  a  dislocation  of  the 
first  phalanx  cannot  be  reduced,  either  as  a  primary  operation  or 
later  on,  in  a  young  and  healthy  patient,  to  whom  the  stiffness  is  a 
serious  drawback. 

An  incisfon,  H  inch  loiig,  on  the  radial  side  will  leave  least  scar; 
the  joint  is  opened,  the  bones  dislocated,  or,  if  this  be  found  diffi- 
cult, the  ends  of  the  bones  may  be  cleared  by  keeping  the  knife- 
point closely  applied  to  them  and  by  retracting  strongly  the  soft 


28  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

parts  ;  the  ends  are  then  removed  in  situ  by  a  narrow  saw  or  osteo- 
tome, which  are  preferable  to  bone-forceps.  The  surgeon  should 
always  remove  the  bones  freely,  and  not  content  himself  with 
paring  off  the  articular  surface,  which  risks  the  formation  of  a  stiff 
joint. 

EXCISION  OF  FINGERS. 
Only  excision  of  joints  need  be  alluded  to  here,  as,  save  in  the 
case  of  removal  of  the  distal  phalanx  for  necrosis,  excision  of  a 
phalanx  leaves  a  very  useless  finger. 

Excision  of  an  Inter-phalangeal  or  Metacarpo-pha- 

langeal  Joint. — This  may  be  called  for  after  a  clean  cut  into  the 
joint  (circular  saw,  etc.) ;  in  the  hope  of  saving  one  or  more  damaged 
fingers  when  several  have  required  amputation  after  a  machinery 
accident;  in  some  cases  of  compound  dislocation;  in  a  few  cases  of 
disease — thus,  in  young  subjects,  in  the  case  of  the  index  finger, 
e.  g.,  where  there  is  only  one  joint  affected,  and  the  mischief  is 
limited  to  the  articular  surfaces  and  the  bones  themselves  are 
sound.  Excision  of  one  of  the  above  joints  is  best  performed  by 
an  incision,  1  to  IJ  inch  long,  to  one  side  of  the  dorsum  of  the  joint. 
The  lateral  ligament  being  severed,  the  joint  is  dislocated,  and  the 
ends  of  the  bones  removed  with  a  narrow  clean-cutting  saw,  the 
soft  parts  being  as  carefully  protected  from  damage  as  possible.* 
Drainage  being  provided  with  aseptic  gut  or  horsehair,  the  wound 
is  partly  closed,  and  the  finger  put  up  somewhat  flexed.f  Careful 
passive  movement  should  lie  commenced  about  the  sixth  day. 

Conservative  Surgery  of  the  Hand.— While  it  is  a  car- 
dinal principle  to  preserve  every  inch  of  the  hand,  and  that  a  single 
finger  or  the  thumb  alone  is  far  more  useful  than  the  most  elaborate 
artificial  limb  that  can  be  made,  and  that  to  gain  this  end  it  is  fre- 
quently advisable  to  trim  up  an  injured  part  and  to  remove  dead 
bone  in  preference  to  doing  any  set  amputation,  it  must  always  be 
remembered  that  a  part  may  be  capable  of  being  saved,  and  yet 
ultimately  be  useless,  unless  it  be  at  least  partially  movable.  Where 
it  is  probable  that  both  flexor  tendons  will  die,  amputation  had 
best  be  performed  in  any  finger  except  the  index. 

One  condition,  which  a  surgeon  in  large  manufacturing  centres  is 
certain  to  meet  with,  requires  grave  consideration,  i.  e.,  where  a 
hand,  often  of  a  boy  or  girl,  is  flayed,  owing  to  its  having  been 
caught  between  rollers  which  hold,  but  do  not  crush ;  here,  as  the 
patient  draws  back,  the  skin  is  stripped  off,  like  a  glove,  up  to  the 
wrist.  If  any  bones  are  crushed,  thecse  or  the  palmar  fascia  opened? 
amputation  at  the  wrist  should  be  performed  at  once ;  and  Billroth 

*  If  any  tendons  are  cut,  they  should  be  united  with  sutures. 

t  On  a  carefully  moulded  felt  splint,  or  one  of  perforated  zinc,  or  of  whalebone. 


EXCISION    OF     FINGERP.  29 

(^Lect.  on  Surg.,  Pathology,  and  Therapeutics,  Syd.  Soc.  Tr.,  vol.  i.  p. 
207)  advises  this  step  where  the  skin  is  completely  stripped  off 
without  other  injury,  fingers  entirely  deprived  of  their  skin  almost 
invariably  becoming  gangrenous,  and  the  result  being,  "under  the 
most  favorable  circumstances,  nothing  more  than  an  unwieldy 
cicatrized  stump."  Probably  most  surgeons  would  make  an  attempt 
in  a  young  subject,  and  with  the  aid  of  antiseptics,  irrigation,  and 
skin-grafting  as  soon  as  possible,  to  save  part  at  least  of  the  hand. 
Dr.  Gregory  {Trans.  Amer.  Surg.  Assoc,  vol.  ii.  p.  232)  mentions 
such  a  case,  in  which  a  boy's  hand  had  been  thus  flayed  without 
further  injury.  "  I  felt  satisfied  that  amputation  was  proper,  but 
the  patient  insisted  that  he  was  willing  to  take  the  risk ;  and  I  re- 

FiG.  8. 


placed  the  flap,  and  stitched  it  in  several  places,  believing  that  it 
would  slough.  It  did  slough,  and  he  lost  his  fingers  up  to  the 
knuckles,  and  the  only  portion  that  was  saved  was  a  small  part  of 
the  thumb  and  the  metacarpal  portion  of  the  hand.  This,  of  course, 
was  a  cicatricial  surface,  which  I  covered  with  grafts,  and  it  finally 
healed.  The  boy  can  hold  a  pen  in  a  little  groove  by  the  side  of 
the  thumb,  and  it  is  probable  that  the  remnant  of  the  hand  will 
finally  become  useful." 

The  foregoing  (Fig.  8)  is  an  excellent  instance  of  what  may  be 
effected  by  conservative  surgery  here.  It  rej^resents  the  relic  of  a 
hand,  consisting  of  the  thumb,  stump  of  the  index  and  of  the  little 
finger,  and  also  shows  how  much  flexion  the  shortened  index  is 
still  capable  of* 

*  The  figure  is  taken  from  a  paper  on  Railway  Injuries,  by  Dr.  Thomson,  of 
Kentucky. —  Trans.  Amer.  Surg.  Assoc,  vol.  ii.  p.  190. 


30  OPERATIONS  ON  THE  UPPER  EXTREMITY. 

REUNION  OF  SEVERED  DIGITS. 

The  question  will  sometimes  arise  as  to  the  advisability  of  at- 
tempting to  reunite  portions  of  severed  fingers  and  thumbs. 

Many  such  successful  cases  have  occurred,  and  the  surgeon  may 
well  make  the  attempt,  when  the  parts  are  cleanly  severed,  and 
when  the  patient  is  young  and  healthy,  as  is  often  the  case  in 
country  practice. 

The  following  are  instances  of  the  parts  severed :  The  first, 
second,  and  third  fingers  cut  off"  above  a  diagonal  line  beginning  in 
the  middle  phalanx  of  index  finger  and  ending  in  last  phalanx  of 
third  finger  near  the  root  of  the  nail.  The  parts  had  been  lying  in 
the  snow  for  some  time,  and  were  kept  for  two  or  three  hours  before 
being  applied.  In  other  cases  the  part  has  been  severed  longitudi- 
nally, containing  in  it  a  portion  of  bone  split  off".  The  time  between 
the  injury  and  the  treatment  has  varied  from  twenty  minutes  to 
three  or  four  hours,  and  the  severed  part  has  been  picked  out  of 
sawdust,  brought  up  in  dirty  paper,  whilst  in  a  third  the  patient 
was  sent  back  to  find  it  in  the  field  in  which  he  had  been  reaping. 

When  there  is  the  least  shred  of  soft  parts  left  holding  on  the 
severed  bit,  even  a  bad  compound  fracture  of  the  finger  with  severe 
laceration  of  the  soft  parts  may  be  saved. 

The  age  and  condition  of  the  patient,  the  time  which  has  elapsed 
since  the  injury,  the  part  affected,  i.  e.,  whether  index  or  thumb, 
must  all  be  considered.  And  in  any  case  the  patient  should  be 
warned  that,  though  the  attempt  may  succeed,  the  parts  unite,  and 
sensation  be  restored,  the  result  may  be  a  stiff  and  therefore  com- 
paratively useless  member. 

If  it  be  decided  to  make  the  attempt,  the  part  should  be  well 
cleansed  with  warm  mercury  perchloride  solution  (1  in  1000), 
united  exact!}'  with  a  few  points  of  fine  wire,  or  carbolized  silk,  and 
horsehair  sutures,  enveloped  in  salicylic  wool,  and  kept  in  situ  with 
carefully-adjusted  splints  of  whalebone  or  perforated  zinc.  The 
dressings  should  not  be  disturbed  for  three  days,  if  possible.* 

WEBBED  FINGERS  (Figs.  9  and  10). 

These  should  always  be  remedied  as  soon  as  possible  in  early 
childhood;  if  left  untouched,  the  fingers  may  be  useful,  but  the 
annoyance  of  the  deformity  will  be  serious. 

*  Numerous  cases  of  this  kind  will  be  found  in  the  Lancet  for  1861,  vol.  ii.,  and 
more  recently  {Annals  of  Surgery,  March,  1887,  p.  263)  fifteen  such  cases,  with  good 
results,  have  been  tabulated  by  Dr.  Pilcher. 


WEBBED    FINGEBS. 


31 


1.  The  simpler  methods — viz.,  wearing  a  large  metal  ring  through 
a  hole  made  where  the  cleft  should  begin,  or  passing  large  silver 
wire  or  fine  drainage-tubing  through  such  a  hole,  the  ends  of  the 
tubing  or  wire  being  attached  to  a  wristlet  or  bracelet — may  be  tried 
first,  and,  when  the  perforation  is  soundly  healed,  the  web  should 
be  slit  up,  and  the  fingers  kept  apart. 

2.  If  the  above  fail,  one  of  the  following  plastic  operations  should 
be  made  use  of: 

Didot's*  (Fig.  9). — Two  narrow  longitudinal  flaps  are  dissected 
up  as  thick  as  possible  from  the  palmar  and  dorsal  aspects  of  the 
affected  fingers,  and  each  flap  is  then  folded  round  to  cover  in  the 


Fig.  9. 


Fig.  10. 


Didot's  operation  for  webbed  fingers.    (Reeves.' 


Norton's  operation  for  webbed  fingers. 


raw  surface  of  the  finger  to  which  it  is  attached,  and  secured  with  a 
few  points  of  very  fine  interrupted  sutures  of  carbolized  silk  and 
horsehair. 

NoRTON'sf  (Fig.  10). — Small  triangular  flaps  are  raised  between 
the  knuckles  on  the  dorsal  and  palmar  aspects ;  the  webs  are  then 
cut  through  and  the  knife  carried  back  so  as  to  sever  all  the  tissues 
up  to  the  bases  of  the  flaps,  which  are  then  very  carefully  stitched 
together  without  tension.     The  object  is  to  insure  rapid  union  in 


*  A  good  account  of  these  operations  will  be  found  in  Mr.  Eeeves's  Orthopcedic 
Surgery. 

t  British  Medical  Journal,  1881,  ii.  931. 


32  OPERATIONS    OX    THE    UPPER    EXTREMITY. 

the  commencement  of  the  cleft,  and  thus  no  redevelopment  of  the 
web.  The  flaps  should  be  sufficiently  thick  to  avoid  the  risk  of 
sloughing,  and  somewhat  narrow  to  prevent  bulging.  To  prevent 
tension  they  should  be  sufficiently  long,  and  any  tissue  between  the 
knuckles  that  prevents  their  coming  together  should  be  cut  away. 
The  line  of  the  natural  web  should  be  carefully  observed. 

CONTRACTED  PALMAR  FASCIA  (Figs.  11  and  12). 

It  is  well  known  that  occasionally  contraction  of  the  palmar 
fascia  takes  place,  especially  that  part  of  it  going  to  the  inner  two 
fingers,  being  due  partly  to  constitutional,  partly  to  local,  causes. 
Commencing  about  the  transverse  jjalmar  creases,  it  steadily  crip- 
ples the  hand  by  drawing  down  the  fingers,  causing  flexion  at  the 
metacarpo- phalangeal  joint  (Fig.  11). 

Operation. — This  may  be  either  open  or  subcutaneous ;  I  much 
prefer  the  latter.  The  best  is  Mr.  Adams's  method,*  by  multiple 
punctures  from  above  downwards.  Either  before  the  skin  becomes 
adherent,  or  by  finding  some  spot  where  adhesion  of  the  skin  to  the 
fascia  has  not  yet  taken  place,  the  surgeon,  avoiding  the  site  of  the 
vessels,  passes  a  delicate  fascia  knife  or  a  fine  small  tenotomy  knife, 
between  the  skin  and  fascia,  and  divides  the  band  from  above 
downwards,  taking  care  not  to  dip  the  point.  In  cases  of  contrac- 
tion of  two  fingers,  multiple  punctures — e.  g.,  five  to  nine — may  be 
required.  It  is  very  easy,  by  operating  on  the  palmar  cords,  to 
rectify  the  contraction  at  the  metacarpo-phalangeal  joint.  The 
straightening  of  the  contraction  often  met  with  between  the  first 
and  second  phalanges  is  much  more  difficult.  The  digital  prolonga- 
tions of  the  fascia  may  be  divided  by  punctures  in  the  web  between 
fingers,  extreme  care  being  required  to  avoid  the  digital  vessels  and 
nerves  by  not  dipping  the  point.  But  when  the  surgeon  finds  some 
difficulty  in  correcting  this  contraction  thoroughly,  I  am  of  opinion 
that  he  will  act  most  wisely  by  correcting  the  remaining  contraction 
gradually  by  the  use  of  a  finger  splint  with  rack  and  pinion  move- 
ments opposite  the  metacarpo-phalangeal  and  inter-phalangeal 
joints.f  When  the  punctures  are  made  they  are  covered  with 
boracic  lint,  dusted  with  iodoform,  and  the  hand  placed  on  the 
above  splint,  which  is  worn  day  and  night  at  first,  carefully  padded 
at  all  pressure  points.  Some  weeks  will  be  required  to  correct  the 
phalangeal  contraction,  and  in  advanced  cases  relapses  can  only  be 


*  Finger  Contraction  and  Depressed  Cicatrices  (Churchill,  1879). 
t  Loc.  supra  cit.,  Fig.  10. 


CONTRACTED    PALMAR    FASCIA. 


33 


prevented  by  the  persevering  use  of  the  splint.  If  the  surgeon 
attempts  to  straighten  completely  in  an  advanced  case  of  phalan- 
geal as  well  as  metacarpo-phalangeal  contraction,  he  runs  the  risk 
(by  dividing  a  digital  nerve)  of  causing  slight  gangrene  of  the 
finger-tips  or  most  intolerable  pain. 

Figs.  11  and  12*  represent  the  right  hand  crippled  with  contrac- 
tion of  the  i^almar  fascia,  before  and  after  operation.     The  man  was 

Fig  11. 


a  patient  of  Dr.  J.  E.  B.  Burroughs,  of  Lee,  and  was  operated  on  by 
me  in  1883,  the  contraction  of  the  metacarpo-phalangeal  joints 
being  straightened  at  once  after  numerous  punctures  made  in  the 
manner  above  given,  while  that  at  the  inter-phalangeal  joints  was 
remedied  chiefly  by  the  persevering  use  of  Mr.  Adams's  splint, 
already  alluded  to.  The.  fingers  are  now,  1887,  absolutely  straight, 
perfectly  mobile,  and  free  from  the  slightest  tendency  to  contrac- 
tion. It  will  be  seen  from  Mr.  Hogarth's  drawing  that  some  thick- 
ening, puckering,  and  corrugation  of  the  palmar  skin  and  fascia 
still  persists,  but  this  has  now  no  power  of  producing  contraction, 

*  The  asterisks  in  Fig.  12  show  spots  where  the  fascia  knife  might  be  introdnced 
in  contraction  of  tlie  palmar  fascia  slip  going  to  the  ring  finger.  The  contracted 
band  or  bridle,  thus  isolated  by  the  punctures,  undergoes  softening  and  atrophy. 

3 


34 


OPERATIONS    ON    THE    UPPER    EXTREMITY. 


the  patient,  one  of  the  reheving  officers  to  the  Lewisham  Union, 
being  able  to  write,  etc.,  without  an_y  hindrance  whatever. 

If  a  method  of  operating  by  open  wound  be  preferred,  the  follow- 
ing, based  upon  that  of  Goyraud,  may  be  made  use  of.  It  is  rec- 
ommended by  Mr.  Hardie,*  of  Manchester,  who  believes  that  mere 
subcutaiieous  division  of  the  contracted  palmar  fascia  cannot  be 
sufficient  if  the  thickened,  puckered,  hardened  skin  is  left  alone, 
and  also  that  intimate  adhesion  of  the  altered  skin  to  the  fascia  is 


Fig.  12. 


SO  general  that  it  is  difficult,  if  not  impossible,  to  get  the  knife  be- 
tween the  two  at  a  sufficient  number  of  spots  for  adequate  straight- 
ening by  the  subcutaneous  method.  While  it  may  be  readily  ad- 
mitted that  Mr.  Hardie's  four  cases  gave  good  results  up  to  the  time 
reported,  and  that,  if  any  open  operation  is  really  needed,  this  one 
is  as  good  as  any,  the  following  objections  to  its  general  adoption  in 
preference  to  that  of  Mr.  Adams  appear  to  me  to  be  fair  ones :  (1) 
The  greater  severity  of  an  open  operation  in  these  patients,  who  are 
often  not  young,  even  when  the  wound  is,  by  hands  as  careful  as 
those  of  Mr.  Hardie,  kept  aseptic.  (2)  The  more  frequent  dress- 
ings, the  need  of  a  drain,  the  fact  that  the  wound  does  not  heal  for 

■*  Medical  Chronicle,  vol.  i.  No.  1,  p.  9. 


CONTE ACTED    PALMAR    FASCIA.  ^35 

upwards  of  a  week,  and  then,  perhaps,  not  all  by  primary  union; 
the  presence  of  sutures  which  need  removal,  and  the  fact  that,  as 
in  C^e  III.,  "  general  swelling  of  the  hand  "  may  take  place  and 
interfere  with  the  use  of  splints.  Finally,  Mr.  Hardie  does  not 
appear  to  me  to  attach  sufficient  importance  to  the  value  of  Mr. 
Adams's  splint,  which,  by  gradual,  quiet,  persevering  extension, 
c^ses  atrophy  of  the  now  divided  fascial  cords,  and  thus  renders, 
as  a  secondary  result,  the  hardened  skin  over  them  more  soft  and 
supple,  this  taking  place  the  more  readily,  the  more  extension  by 
the  splint,  and  passive  movements,  frictions,  etc.,  are  persevered 
with. 

Mr.  Hardie  thus  describes  his  modification*  of  Goyraud's  opera- 
tion : 

"  An  Esmarch's  tourniquet  having  been  applied,  an  incision  is 
begun  ^  i^h  above  the  principal  transverse  fold  of  the  palm,  imn)e- 
diately  over  the  tense  bridle  of  fascia  proceeding  to  the  finger  mainly 
involved.  This  is  carried  along  the  bridle  to  a  little  beyond  the 
base  of  the  las^t  phalanx  which  is  affected.  The  lips  of  the  incision 
having  been  opened  up,  the  knife  is  then  carried  close  to  the  bridle 
along  its  whole  extent,  so  as  to  separate  from  it  the  adjacent  skin, 
cellular  tissue,  and  fat,  first  on  one  side  and  then  on  the  other.  In 
doing  this,  it  is  necessary  to  go  some  depth  near  the  upper  end  of 
the  incision,  so  as  to  divide  the  little  bands  which  attach  the  web  of 
the  finger  to  the  processes  of  fascia  inserted  into  the  sides  of  the 
first  phalanx.  This  dissection  having  been  completed,  the  tense 
bridle  of  fascia,  now  almost  isolated,  is  cut  across  at  the  upper  end 
of  the  incision.  This  immediately  permits  of  an  almost  complete 
extension  of  the  first  phalanx.  Further  transverse  incisions  are 
then  made  opposite  the  middle  of  the  first  and  second  phalanges, 
as  the  case  may  require.  The  knife  is  then  applied  to  any  portion 
of  the  fascia  which  appears  to  prevent  complete  extension  of  the 
fingers.  Some  portions  may  then  appear  to  be  so  much  isolated,  or 
may  project  so  much,  that  they  may  be  cutout  entirely.  The  other 
fingers  of  the  same  hand  which  are  affected  are  then,  in  their  turn, 
similarly  treated.  Complete  capability  of  immediate  extension  is 
to  be  secured.  The  tourniquet  is  then  removed,  but,  although  the 
bleeding  will  be  very  smart,  it  is  not  likely  that  any  vessels  will  be 
seen  which  can  be  secured.  I  then  lay  a  catgut  or  horsehair  drain 
along  the  extent  of  the  wound,  and  bring  the  edges  of  the  latter 
accurately  together  with  silver  wire.  A  large  pad  of  antiseptic 
dressing  is  applied,  and  the  fingers  bandaged  to  a  straight  splint. 

*  The  chief  points  of  difference  are  that  more  importance  is  attached  by  Mr. 
Hardy  to  complete  liberation  of  the  skin,  and  that  the  antiseptic  treatment  is  made 
use  of. 


36  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

I  regret  to  have  to  use  a  drain,  but  the  bleeding  is  so  free  that  I 
think  it  a  desirable  precaution.  It  should  be  removed  next  day,  and 
the  dressing  re-a])plied  so  as  to  exert  some  pressure  on  the  part. 
Should  nothing  untoward  occur,  it  should  be  left  undisturbed  for  a 
week,  when  it  is  to  be  expected  that  sound  union  will  have  taken 
place.  The  stitches  are  removed,  and  subsequent  treatment  will 
consist  in  manipulation  of  the  fingers  and  the  use  of  the  splint  for 
two  or  three  weeks  longer." 

PALMAR  HAEMORRHAGE. 

Before  considering  this^  it  may  be  pointed  out  that  there  are 
three  arterial  arches  especially  concerned  in  keeping  up  the  arterial 
supply  here — viz.  (a)  superficial  palmar;  (/5)  deep  palmar  arch;  (y) 
the  carpal  arteries  round  the  wrist.  These  are  supplied  with  blood, 
not  only  from  the  radial  and  ulnar,  but  also  from  the  interosseous 
arteries.  Finally,  if  the  comes  nervi  mediani  is  enlarged,  it  will 
join  the  superficial  palmar  arch  or  one  of  the  digital  arteries. 

Treatment. — This  will  vary  accordingly  as  the  c^ise  is  seen  early 
or  later. 

A.  Early  Cases. — The  surgeon  arrests  any  bleeding*  by  pressure 
on  the  bleeding  point  while  he  has  the  limb  raised,  and  arranges 
for  compressing  the  brachial,  or  the  radial  and  ulnar.  This  securely 
effected,  he  cleanses  the  wound,  dries  it  carefully,  and,  if  it  gapes  at 
all,  endeavors  to  secure  the  cut  vessel  itself.  If  this  fail,  or  if  the 
wound  be  merely  punctured,  he  at  once  carefully  applies  compres- 
sion. And  it  may  be  said  at  once  that,  if  this  is.  wisely  and  effi- 
ciently done,  no  further  haemorrhage  will  take  place;  if  incompletely 
or  carelessly  applied,  the  patient's  limb  and  life  may  both  be  en- 
dangered. 

The  brachial  being  commanded  and  the  wound  dried,  a  compress 
— consisting  of  boracic  lint,  dusted  with  iodoform,  pieces  of  sponges 
wrung  out  of  carbolic  acid  and  dusted  with  iodoform  and  powdered 
steel  sulphate,  or  lint  soaked  in  carbolic  oil  or  tr.  benz.  co.,  the 
pieces  of  lint  or  sponge  increasing  in  size  from  a  threepenny  bit  to 
half-a-crown — is  got  ready,  together  with  strapping,  bandages,  lint, 
and  two  bits  of  pencil  or  bougie.  The  fingers  are  now  carefully 
strapped  and  bandaged,  and  the  compress  is  then  secured  in  posi- 
tion by  careful  bandaging.  If  the  above  precaution  is  omitted,  so 
much  and  so  painful  oedema  of  the  fingers  will  take  place  as  to 

*  The  wound  sometimes  does  not  bleed  when  examined.  If  tliere  is  a  liistory 
of  much  bleeding,  bleeding  pe?- sa/<(im,  if  the  depth,  etc.,  of  the  wound  make  it 
probable  that  an  artery  is  wounded,  pressure  should  be  applied.  A  little  later,  and 
the  hsemorrhage  may  break  out  on  tlie  least  exertion,  and  is  very  likely  to  occur  at 
night. 


PALMAR    H^MOERHAGE.  37 

inevitabh'  lead  to  early  removal  o4'  the  compress  and  recurrence  of 
the  hannorrhage.  The  compress  being  in  position,  two  bits  of 
pencil  wrapped  up  in  lint  are  placed  over  the  radial  and  ulnar,  and 
the  bandage  carried  up  to  mid-arm.  The  Esmarch  being  removed 
from  the  brachial,  a  splint*  is  then  applied,  and  the  patient  kept  at 
first  well  under  the  influence  of  morphia.  The  compress  should 
not  be  disturbed  for  three  or  four  days  at  least. 

B.  I.ATER  Cases. — If  pressure  has  been  tried,  but  inefficiently, 
because  inadequately  at  first,  inflammation  will  probably  have 
supervened,  and  the  hand  will  very  likely  be  red,  brawny,  painful, 
suppurating.  If  ha?morrhage  still  continue  after  the  parts  are  re- 
lieved by  carefully  made  incisionsf  it  will  be  wiser  to  tie  the  brachial 
artery  at  once  in  the  middle  of  the  arm  than  to  tie  the  radial  and 
ulnar  in  the  lower  third  of  the  forearm  CP-  37,  40),  and  for  these 
reasons : 

i.  While  the  anastomoses  round  the  elbow  are  so  free  and  so  re- 
liable as  to  prevent  any  risk  of  gangrene  after  a  ligature  of  the 
main  vessel,  ligature  of  the  radial  and  ulnar  is  rendered  uncertain 
owing  to — 

(«)  The  anastomoses  between  the  two  palmar  arches ; 
(/5)  The  anastomoses  between  these  and  the  carpal  arteries ; 
(y)  The  blood  brought  down  by  the  interosseous  arteries  and 
the  comes  nervi  mediani,  which  will  not  be  stoj^ped  by 
ligature  of  the  radial  and  ulnar; 
(S)  The  fact  that,  if  inflammation  17as  set  in,  enlargement  of 
the  arteries  will  have  taken  place, 
.ii.  Ligature  of  the  brachial,  by  cutting  off  so  much  blood,  will 
also  cut  short  the  inflammation. 

iii.  Ligature  of  the  brachial  will  be  performed  through  healthy 
and  uninflamed  parts. 

An  interesting  instance  of  what  pressure  will  effect  even  if  de- 
ferred till  the  eleventh  hour  is  seen  in  the  following  case,  published 
by  Mr.  Skey,  Lancet,  1855.  A  patient  nearly  three  weeks  after  the 
wound,  having  had  attacks  of  recurrent  ha}morrhage,  entered  St.  Bar- 
tholomew's Hospital,  and  Mr.  Skey  tied  the  radial  and  ulnar.   When 

*  The  surgeon  must  choose  between  one  (e.g.,  an  outside  angular  splint)  in  which, 
the  hand  being  extended,  the  tension  of  the  palmar  fascia  makes  some  pressure  on 
the  wounded  vessel,  and  one  more  comfortable,  but  perhaps  less  efficient,  in  which 
the  hand  is  flexed  and  the  fascia  relaxed. 

f  Incisions  for  suppuration  in  the  hand  should  be  made  opposite  to  the  centres 
of  the  phalanges,  opposite  to  the  heads  of  the  metacarpal  bones,  above  the  super- 
ficial palmar  arch  by  Mr.  Hilton's  method,  and,  if  above  the  wrist,  the  position  of 
the  arteries,  which  may,  perhaps,  be  superficial,  and  of  the  median  nerve  lying 
close  to  the  inner  side  of  the  palmaris  longus  must  be  remembered. 


38  OPERATIONS  ON  THE  UPPER  EXTREMITY. 

the  ligature  separated  from  the  uhiar,  haemorrhage  took  place,  and 
the  artery  was  again  tied  in  the  middle  third.  Haemorrhage  recur- 
ring, the  brachial  was  tied  in  the  lower  third.  This  last  operation 
failed  to  arrest  the  haemorrhage,  and  the  third  part  of  the  axillary 
was  tied.  About  ten  days  later  profuse  haemorrhage  from  the  axil- 
lary wound  left  the  patient  almost  pulseless.  The  patient's  con- 
dition not  admitting  of  amputation  at  the  shoulder,  the  limb  was 
firmly  bandaged  from  the  hand  to  the  shoulder.  No  further  bleed- 
ing took  place,  and  the  man  made  a  good  recovery,  with  a  useful 
arm. 

In  the  Lancet,  1859,  vol.  i.  p.  506,  is  a  good  instance  of  the  results 
of  pressure  inefficiently  applied.  The  compress,  which  had  been 
applied  to  the  palmar  wound  (the  man  having  been  made  an  out- 
patient), was  removed  every  day,  and  followed  by  ha?morrhage. 
Severe  bleeding  occurred  on  the  fifth  day,  ligature  of  the  radial  was 
performed  on  the  seventh,  and  on  the  ninth  ligature  of  the  brachial 
low  down.  On  the  eleventh,  owing  to  recurrence  of  haemorrhage, 
the  arm  was  amputated  just  above  the  ligature.  Chronic  pyaemia 
followed,  from  which  the  patient  was  slowly  recovering  at  the  close 
of  the  report.  No  abnormal  distribution  of  vessels  was  found  in 
the  arm. 

OPERATIONS  FOR  UNION  OF  DIVIDED  TENDONS. 

These  may  be  referred  to  here  from  the  frequency  Avith  which  the 
flexor  and  extensor  tendons  of  the  fingers  and  wrist  are  liable  to  be 
severed. 

As  in  the  case  of  divided  nerves,  the  union  of  tendons  may  be 
primary  or  secondar}^  according  as  the  surgeon  is  called  to  the  case 
at  once  or  later.  For  general  details  the  reader  is  referred  to  the 
chapter  on  Nerve-suture. 

The  upper  end  will  probably  give  more  trouble  than  in  the  case 
of  a  nerve,  owing  to  its  greater  retraction.  In  laying  open  the 
sheath  to  follow  up  the  tendon,  most  scrupulous  care  must  be  taken 
to  use  every  aseptic  precaution.  Sutures  of  fine  silk,  salmon-gut, 
or  silk  combined  with  horsehair  are  preferable  to  those  of  chromic 
gut.*  In  the  case  of  secondary  suture,  refreshing  the  ends  must  be 
made  use  of. 

When  several  tendons  have  been  divided,  uniting  each  end  accu- 
rately to  its  fellow  is  often  troublesome. 

If  the  upper  end  cannot  be  found  after  careful  search  and  suffi- 
cient slitting  up  of  the  sheath,  the  lower  end  may  be  successfully 
attached  to  a  neighboring  tendon. 

*  Silk  or  wire  sutures  should  always  be  used  when  suppuration  is  likely  to  take 
place. 


UNION    OF    DIVIDED    TENDONS.  39 

When  the  ends  are  widely  apart,  and  apposition  is  unobtainable, 
attempts  have  recently  been  made,  with  some  success,  to  connect 
the  two  ends  by  long  threads — "  distance-sutures."  B.  Anger  first 
made  use  of  sutures  of  this  kind  for  the  tendon  of  the  extensor 
minimi  digiti ;  the  two  ends  were  9  cm.  apart,  but  traction  reduced 
the  distance  to  2  cm.,  and  they  were  connected  by  a  silver  suture, 
with  a  satisfactory  result.  M.  Assaky,*  and  M.  Fargin,  have  more 
lately  used  distance-sutures,  and  think  that  the  tendons  regenerated 
along  the  threads  are  always  stronger  than  those  spontaneously 
regenerated,  the  number  of  tendinous  fasciculi  being  greater.  The 
operation  is  clearly  indicated  whenever  apposition  is  impossible;  it 
is  more  particularly  applicable  to  tendons  without  a  sheath. 

M.  Peyrotf  has  succeeded  in  transplanting  the  tendons  of  a  dog, 
and,  in  another  case,  that  of  a  cat,  into  the  gaps  of  divided  tendons 
in  man.  The  transplanted  piece  is  said  to  have  lived,  and  a  fair 
amount  of  flexion  of  the  finger  to  have  been  obtained.  Whether 
this  will  be  found  preferable  in  its  results  to  distance-sutures  re- 
mains to  be  seen. 

The  following  cases  are  good  instances  of  tendon  suture ;  they 
are  reported  by  Dr.  v.  Fillenbaum,  of  Vienna: J 

Case  I. — Oblique  cut  with  a  bread-knife,  involving  the  common 
extensor  of  the  index  and  middle  finger,  and  the  extensor  indicis, 
the  central  end  of  the  latter  retracted  so  far  that  it  could  not  be 
reached,  unless  by  slitting  up  its  sheath.  The  tendons  of  the  com- 
mon extensor  were  each  united  by  two  fine  silk  sutures. 

The  accessible  peripheral  end  of  the  extensor  indicis  was  attached 
to  both  ends  of  the  sutured  tendon  from  the  extensor  commu- 
nis to  the  index  finger.  The  strongly  stretched  extensor  tendons 
of  the  second  and  third  fingers  were  now  fixed  (to  prevent  retrac- 
tion by  muscular  action)  by  silk  sutures  passed,  2  cm.  higher  up, 
through  skin  and  tendon  sheath,  and  tied  over  a  roll  of  iodoform 
gauze.  These  were  removed  on  the  fifth  day.  Passive  movement 
was  begun  on  the  sixteenth  day.  Six  months  later  the  man  had 
perfect  use  of  his  fingers. 

Case  II. — Razor  cut  on  back  of  left  thumb  ;  operation  six  weeks 
later.  The  thumb  was  found  strongly  adducted,  and  bent  into  the 
palm.  Active  extension  impossible.  A  serous  fistula  was  left.  The 
parts  being  made  evascular,  the  tendon-ends,  found  but  a  few  mm. 

*  The  above  remarks  on  distance-sutures  are  taken  from  an  abstract  of  a  paper 
by  M.  Assaky,  Revue  de  Chirurgie,  November,  1886,  in  the  Annals  of  Surgery,  April, 
1887,  p.  348. 

t  Bull,  de  la  Soc.  de  Chir.,  1886,  p.  357. 

I  Wien.  Med.  Woch ,  Nos.  29  and  30,  1885;  Annals  of  Surgery,  November,  1885, 
p.  427. 


40  OPERATIONS  ON  THE  UPPER  EXTREMITY. 

apart  and  closely  adlierent  to  the  sheath,  were  trimmed  with 
scissors  and  united  with  silk  sutures.  Two  mm.  above  the  central 
end  on  the  radial  side  a  fine  silk  suture  was  passed  outwards,  and 
again  in  towards  the  palm,  through  the  whole  thickness  of  the  ten- 
don, then  back  again  towards  the  palm,  and  out  at  the  ulnar  side. 
After  closely  adapting  the  two  tendon-ends,  the  silk  was  passed 
through  the  peripheral  end  in  a  reverse  order,  and  finally  the  two 
suture  ends  were  tied  on  the  radial  side  of  the  tendon.  A  fixation- 
suture  was  used  as  in  the  previous  case.  Four  months  later  the 
movements  of  the  thumb  were  normal,  only  at  the  place  of  the 
fixation  suture  the  skin  and  tendon  sheath  were  adherent,  as  shown 
by  the  folding  in  of  the  skin  on  extension. 

Case  III. — The  tendon  of  the  extensor  minimi  digiti  was  severed. 
Its  central  end  was  only  found  after  slitting  up  the  sheath  2i  cm. 
Result  excellent. 

Case  IV. — Extensor  of  left  middle  finger  was  severed  close  to  the 
head  of  the  second  phalanx,  the  adjacent  joint  being  opened.  The 
articular  capsule  was  first  closed,  then  the  tendon  was  sutured  as 
well  as  possible,  much  difficulty  arising  from  the  thinness  of  the 
middle  crus  of  the  extensor  here.  The  wound  united  well.  The 
finger,  at  first  straight,  gradually  became  more  and  more  flexed, 
and  worse  than  useless.     A  further  operation  was  refused. 


CHAPTER   II. 
OPERATIONS  ON  THE  WRIST. 

EXCISION   OF   THE   WRIST  JOINT  (Figs.  13  and  14). 

The  reasons  for  this  operation  often  failing,  and  the  conditions 
needful  for  success,  may  be  first  considered. 

1.  AVhether  the  disease  begins  in  the  synovial  membrane  as  a 
synovitis,  pulpy,  gonorrhoeal,  rheumatic,  etc.,  or  whether,  as  more 
rarely,  it  begins  primarily  in  the  Ijones,  it  extends  rapidly,  not  only 
to  the  wrist-joint,  but  to  the  two  rows  of  carpal  bones  and  the  bases 
of  the  metacarpals,  along  the  complicated  synovial  membranes,* 

*  The  arrangement  of  these,  five  in  number,  must  be  remembered,  and  their 
close  vicinity  to  each  other.  (1)  The  membrana  sacciformis  of  the  inferior  radio- 
ulnar articulation,  passing  from  the  lower  end  of  the  ulna  to  the  sigmoid  cavity  of 
the  radius,  and  lining  tlie  upper  surface  of  the  triangular  fibro-cartilage.  (2)  That 
of  tlie  wrist-joint  proper,  passing  from  the  lower  end  of  the  radius  and  the  inter- 
articular  fibro-cartilage  above  to  the  bones  of  the  first  row  below.    (3)  The  common 


EXCISION    OF    THE    WRIST. 


41 


which  l)ring  all  these  bones  into  contiguity  with  each  other.  The 
disease,  thus  extensive,  is  also  most  obstinate,  and  is  by  no  means 
unfrequently  further  complicated  by  the  presence  of  phthisis.  Thus, 
partial  operations  are  useless,  and  often  worse  than  useless.  Sir  J. 
Lister*  was  the  first  to  insist  on  the  importance,  and  to  show  the 
possil)ility,  of  removing  every  atom  of  the  disease,  including  the 
ends  of  the  radius  and  ulna,  the  two  rows  of  carpal  bones,  and  the 
bases  of  the  metacarpus  (Fig.  13). 

2.  From  the  close  relation  of  the  tiexor  and  extensor  tendons  in 
front  and  behind  these  complicated  joints,  and  from  the  numerous 
grooves  on  the  bones,  it  is  most  difficult  to  extirpate  the  disease 

Fig.  1R. 


Parts  removed  in  excision  of  the  wrist.    (Lister.) 

without  disturbing  the  tendons.  On  the  other  hand,  however  stiff 
the  wrist  may  be  left,  flexion  and  extension  of  the  fingers  is  abso- 
lutely needful  for  the  operation  to  be  a  success;  hence  it  is  impera- 
tive that,  throughout  the  prolonged  operation,  the  tendons  should 
be  disturbed  as  little  as  possible,  a  direction  very  difficult  to  follow, 
as  their  cellular  sheaths  are  often  "  pulpy,"  and  the  necessary  dealing 

synovial  membrane  of  the  carpus,  the  most  extensive  of  all,  passing  from  the  lower 
surface  of  the  scaphoid,  semilunar,  and  cuneiform  above  to  the  upper  surface  of  the 
bones  of  the  second  row,  sending  up  two  prolongations  between  the  scaphoid  and 
semilunar  and  the  semilunar  and  cimeiform,  and  also  sending  downwards  three 
processes  between  the  four  bones  of  the  second  row,  prolonged  down  into  the  carpo- 
metacarpal joints  of  the  four  inner  metacarpal  bones.  (4)  A  separate  one  between 
tlie  cuneiform  and  pisiform.  (5)  Another  separate  one  between  the  trapezium  and 
metacarjjal  bone  of  the  thumb. 
*  Lancet,  1865,  vol.  i.  p.  308.     From  this  paper  Fig.  13  is  taken. 


42 


OPERATIONS   ON    THE   UPPER    EXTREMITY. 


with  this,  as  well  as  the  manipulations  of  the  tendons*  during  the 
operation,  may  easily  lead  to  their  sloughing,  and  thus  to  a  useless, 
"  fin-like  "  hand. 

3.  Passive  movement  of  the  fingers  should  be  begun  as  early  as 
possible,  and  most  perseveringly  maintained. 

Sir  J.  Lister's  Operation. f — An  anaesthetic  being  given,  and 

the  parts  rendered  bloodless  by  Esmarch's  bandages,  any  adhesions 

of  the  tendons  are  thoroughly  broken  down.     The  radial  incision 

is  then  made,  as  in  Fig.  14.    This 
Fig.  14.  •      •  •        •       i  i       ^  -j 

mcision  is  planned  so  as  to  avoid 

the  radial  artery  and  also  the 
tendons  of  the  extensor  secundi 
internodii  and  indicis.  It  com- 
mences above  at  the  middle  of 
the  dorsal  aspect  of  the  radius 
on  a  level  with  the  styloid  pro- 
cess. Thence  it  is  at  first  directed 
towards  the  inner  side  of  the  me- 
tacarpo-phalangeal  joint  of  the 
thumb,  running  parallel  in  this 
course  to  the  extensor  secundi  in- 
ternodii ;  but  on  reaching  the 
line  of  the  radial  border  of  the 
second  metacarpal  bone,  it  is  car- 
ried downwards  longitudinally 
for  half  its  length,  the  radial 
artery  being  thus  avoided,  as  it 
lies  a  little  farther  out.  These 
directions  will  be  found  to  serve, 
however  much  the  parts  may  be 
obscured  by  inflammatory  thick- 
ening. The  tendon  of  the  ex- 
tensor carpi  radialis  longior  is  next  detached  with  the  knife,  guided 
by  the  thumb-nail,  and  raised,  together  with  that  of  the  extensor 


A,  Radial  artery.  B,  Extensor  secundi  in- 
ternodii pollicis.  c,  Extensor  indicis.  d, 
Extensor  communis,  e,  Extensor  minimi 
digiti.  F,  Extensor  primi  internodii.  g, 
Extensor  ossis  metacarpi.  h.  Extensor  carpi 
radialis  longior.  i,  Extensor  carpi  radialis 
brevior.  k,  Extensor  carpi  ulnaris.  l  l, 
Line  of  radial  incision.    (Lister.) 


*  Mr.  Erichsen  [Surg.,  vol.  ii.  p.  383)  writes  thus  of  this  point:  "If  we  look  at 
the  tendons  which  surround  the  wrist,  we  shall  find  them  divisible  into  five  groups 
— (1)  Those  special  to  the  tluimb ;  (2)  The  extensors  of  the  fingers ;  (3)  The  flexors 
of  the  fingers ;  (4  and  5)  The  flexors  and  extensors  of  the  wrist.  Now,  the  incisions 
should  be  so  planned  as  to  save  absolutely  the  whole  of  the  first  three  groups  and  to 
divide  only  the  tendons  of  the  wrist  proper,  and  these  are  cut  so  close  to  their  in- 
sertions that,  as  a  rule,  they  form  new  attachments  and  resume  their  functions  as 
recovery  takes  place." 

t  This  account  is  taken  from  Sir  J.  Lister's  original  paper  in  the  Lancet,  loc. 
supra  cit. 


EXCISION    OF   THE    WEIST.  43 

brevior,  also  cut,  while  the  extensor  seciindi  internodii,  with  the 
radial  artery,  is  thrust  somewhat  outwards.  The  next  step  is  the 
separation  of  the  trapezium  from  the  rest  of  the  carpus  by  cutting 
forceps  applied  in  a  line  with  the  longitudinal  part  of  the  incision, 
great  care  being  taken  of  the  radial  artery.  The  removal  of  the 
trapezium  is  left  till  the  rest  of  the  carpus  has  been  taken  away, 
when  it  can  be  dissected  out  without  much  difficulty,  whereas  its 
intimate  relations  with  the  artery  and  neighboring  parts  would 
cause  much  trouble  at  an  earlier  stage.  The  soft  parts  on  the  ulnar 
side  are  next  dissected  up  as  far  as  possible,  the  hand  being  bent 
back  to  relax  the  extensors. 

The  ulnar  incision  should  be  made  very  free  by  entering  the 
knife  at  least  two  inches  above  the  end  of  the  ulna  immediately 
anterior  to  the  bone,  and  carrying  it  down  between  the  bone  and 
flexor  carpi  ulnaris,  and  on  in  a  straight  line  as  far  as  the  middle 
of  the  fifth  metacarpal  bone  at  its  palmar  aspect.  The  dorsal  lip  of 
the  incision  is  then  raised,  and  the  tendon  of  the  extensor  carpi 
ulnaris  cut  at  its  insertion,  and  its  tendon  dissected  up  from  its 
groove  in  the  ulna,  care  being  taken  not  to  isolate  it  from  the  in- 
teguments, which  would  endanger  its  vitality.  The  finger  extensors 
are  then  separated  from  the  carpus,  and  the  dorsal  and  internal 
lateral  ligaments  of  the  wrist-joint  divided,  but  the  connections  of 
the  tendons  with  the  radius  are  purposely  left  undisturbed.  Atten- 
tion is  now  directed  to  the  palmar  side  of  the  incision.  The  ante- 
rior surface  of  the  ulna  is  cleared  by  cutting  towards  the  bone  so  as 
to  avoid  the  artery  and  nerve,  the  articulation  of  the  pisiform  bone 
opened,  if  that  has  not  been  already  done  in  making  the  incision, 
and  the  flexor  tendons  separated  from  the  carpus,  the  hand  being 
depressed  to  relax  them.  While  this  is  being  done,  the  knife  is 
arrested  bj^  the  unciform  process,  which  is  clipped  through  at  its 
base  with  pliers.  Care  is  taken  to  avoid  carrying  the  knife  farther 
down  the  hand  than  the  bases  of  the  metacarpal  bones,  for  this, 
besides  inflicting  unnecessary  injury,  would  involve  risk  of  cutting 
the  deep  palmar  arch.  The  anterior  ligament  of  the' wrist-joint  is 
also  divided,  after  which  the  junction  between  carpus  and  meta- 
carpus is  severed  with  cutting  pliers,  and  the  carpus  is  extracted 
from  the  ulnar  incision  with  sequestrum  forceps,  and  touching  with 
the  knife  any  ligamentous  connections.  The  hand  being  now  for- 
cibly everted,  the  articular  ends  of  the  radius  and  ulna  will  pro- 
trude at  the  ulnar  incision.  If  they  appear  sound,  or  very  super- 
ficially affected,  the  articular  surfaces  only  are  removed.  The  ulna 
is  divided  obliquely  with  a  small  saw,  so  as  to  take  away  the 
cartilage-covered  rounded  part  over  which  the  radius  sweeps,  while 
the  base  of  the  styloid  process  is  retained.     The  ulna  and  radius 


44  OPERATIONS   ON    THE   UPPER   EXTREMITY. 

are  thus  left  of  the  same  lengt]i,  Avhich  greatly  promotes  the  sym- 
metry and  steadiness  of  the  hand,  the  angular  interval  between  the 
bones  being  soon  filled  up  with  fresh  ossific  deposit.  A  thin  slice 
is  then  sawn  off  the  radius  parallel  with  the  articular  surface.  For 
this  it  is  scarcely  necessary  to  disturb  the  tendons  in  their  grooves 
on  the  back,  and  thus  tlie  extensor  secundi  internodii  may  never 
ap])ear  at  all.  This  may  seem  a  refinement,  but  the  freedom  with 
which  the  thumb  and  fingers  can  be  extended,  even  within  a  day 
or  two  of  the  operation,  when  this  point  is  attended  to,  shows  that 
it  is  important.  The  articular  facet  on  the  ulnar  side  of  the  bone  is 
then  clipped  away  with  forceps  applied  longitudinally. 

If  the  bones  prove  to  be  deeply  carious,  the  pliers  or  gouge  must 
be  used  with  the  greatest  freedom.  The  metacarpal  bones  are  next 
dealt  with  on  the  same  principle,  each  being  closely  investigated, 
the  second  and  third  being  most  readily  reached  from  the  radial, 
the  fourth  and  fifth  from  the  ulnar  side.  If  they  seem  sound,  the 
articular  surfaces  only  are  clipped  off,  the  lateral  facets  being  re- 
moved by  longitudinal  application  of  the  pliers.* 

The  trapezium  is  next  seized  with  forceps  and  dissected  outf 
without  cutting  the  tendon  of  the  flexor  carpi  radialis,  which  is 
firmly  bound  down  in  the  groove  on  the  palmar  aspect,  the  knife 
being  also  kept  close  to  the  bone  so  as  to  avoid  the  radial.  The 
thumb  being  then  pushed  up  by  an  assistant,  the  articular  end  of 
its  metacarpal  bone  is  removed.  Though  this  articulates  by  a  sep- 
arate joint,  it  may  be  affected,  and  the  symmetry  of  the  hand  is 
promoted  by  reducing  it  to  the  same  level  as  the  other  meta- 
carpals. 

Lastly,  the  articular  surfiice  of  the  pisiform  is  clipped  off,  the  rest 
being  left  if  sound,  as  it  gives  insertion  to  the  flexor  carpi  ulnaris 
and  attachment  to  the  anterior  annular  ligament.  But  if  there  is 
any  suspicion  as  to  its  unsoundness,  it  should  be  dissected  out 
altogether,  and  the  same  applies  to  the  process  of  the  unciform. 

The  only  tendons  divided  are  the  extensors  of  the  carpus,  for  the 
flexor  carpi  radialis  is  inserted  into  the  second  metacarpal  below 
its  base,  and  so  escapes.  Merely  one  or  two  small  vessels  require 
ligature.     Free  drainage  must  be  given.     The  hand  and  forearm  are 

*  As  an  instance  of  wliat  may  be  taken  away,  in  one  case  Sir  J  Lister  not  only 
removed  tiie  base  of  the  third  metacarpal  bone,  but  drilled  its  sliaft  into  a  hollow 
tube,  a  sound  and  most  useful  hand  being  retained. 

t  Mr.  Williams  {Lancet,  1880,  ii.  p.  932)  advises  that  the  trapezium  should  be 
left,  as,  owing  to  the  special  synovial  sac,  disease  there  is  less  frequent  than  might 
be  expected,  and  as  there  is  thus  no  risk  of  dividing  the  radial  artery  or  the  flexor 
carpi  radialis.  A  single  incision  along  tlie  back  of  the  wrist  at  the  inner  border  is 
recommended  for  excision  of  the  wrist,  but  no  cases  are  given. 


EXCISION    OF    THE    \yRIST.  "45 

put  up  on  the  well-known  splint  of  Sir  J.  Lister,  with  the  cork  sup- 
jDort  for  the  hand,  which  helps  to  secure  the  principal  objects  in  the 
after  treatment,  viz.,  frequent  movements  of  the  fingers,  while  tlie 
wrist  i's  kept  fixed  during  consolidation. 

Passive  movement  should  be  commenced  on  the  second  day, 
whether  the  inflammation  has  subsided  or  not,  and  continued  daily. 
Each  joint  should  be  flexed  and  extended  to  the  full  extent  possible 
in  health,  the  metacarpal  bone  being  held  quite  steady  to  avoid  dis- 
turbing the  wrist.  By  this  means  the  suppleness  gained  by  break- 
ing down  adhesions  under  chloroform  is  maintained. 

Pronation  and  supination,  flexion  and  extension,  abduction  and 
adduction,  must  be  gradually  encouraged  as  the  new  wrist  acquires 
firmness.  When  the  hand  has  acquired  sufficient  strength,  freer 
play  for  the  fingers  should  be  allowed  by  cutting  off  all  the  s})lint 
beyond  the  knuckles.  Even  after  the  hand  is  healed,  a  leather 
support  should  be  worn  for  some  time,  accurately  moulded  to  the 
front  of  the  limb,  reaching  from  the  middle  of  the  forearm  to  the 
knuckles,  and  sufficiently  turned  up  at  the  ulnar  side.  This  is 
retained  in  situ  by  lacing  over  the  back  of  the  forearm. 

Other  Methods  of  Wrist  Excision : 

West's. — In  this  method  two  dorsal  incisions  are  made  use  of, 
each  about  four  inches  long,  the  radial  one  keeping  to  the  ulnar  side 
of  the  extensor  secundi  internodii  poUicis,  the  ulnar  being  rather  to 
the  anterior  surface  of  the  ulna,  but  close  to  the  bone.  No  tendons 
of  the  thumb  or  fingers  are  divided,  being  drawn  aside  with 
retractors.  The  two  cases  reported  (Dublin  Med.  Journ.,  Feb.,  1870) 
recovered  with  very  useful  hands. 

By  Single  Dorsal  Incision. — Dr.  Gillespie  (Edin.  Med.  Joitrn., 
Dec,  1870)  gives  two  cases  in  which  a  single  dorsal  median  incision, 
about  three  inches  long,  was  made  use  of  on  the  outer  side  of  the 
finger  extensors.  The  ends  of  the  ulna  and  radius  were  first  dealt 
with,  then  the  bones  of  the  carpus,  and,  lastly,  those  metacarpals 
which  required  it.  Very  useful  hands  resulted,  especially  in  one 
case,  a  child  of  six.  My  old  friend  G.  A.  Wright,  of  the  Manchester 
and  Pendlebury  hospitals,  has  made  use  of  a  similar  incision.  The 
following  account  is  taken  from  the  Abstracts  of  Medical  and  Sur- 
gical Cases  treated  at  the  Pendlebury  Hospital,  1884,  p.  133.  The 
patient  was  a  child  of  nine,  with  phlyctenular  ophthalmia,  enlarged 
glands,  and  many  marks  of  strumous  disease.  The  right  wrist  Avas 
disorganized.  "  A  single  longitudinal  incision  for  3  to  4  inches  was 
made  between  extensor  communis  and  extensor  secundi,  the  carpal 
joints  opened,  and  the  bones  easily  shelled  out ;  the  ends  of  the 
metacarpal  bones  and  of  the  radius  and  ulna  were  removed  with  a 


46  OPERATIONS    OX    THE    UPPER    EXTREMITY. 

gouee ;  one  vessel  was  twisted ;  no  tendon  was  divided,  except  in 
the  sense  of  turning  back  the  extensors  of  the  carpus  from  their 
attachments."  The  result  was  that,  six  months  later,  "  the  hand, 
which  before  the  operation  was  bulbous,  flabby,  and  useless,  was 
all  but  healed,  and  had  well  shrunken ;  there  was  excellent  power 
and  mobility."* 

A  further  trial  of  this  simple  method  is  required,  especially  in 
adults,  before  a  decided  opinion  can  be  given  as  to  its  merits.  In 
children  the  tendons  can  be  more  readily  drawn  out  of  the  way, 
and  the  parts  are  altogether  less  rigid.  In  endeavoring  to  perform 
an  extensive  excision,  such  as  Sir  J.  Lister  has  shown  to  be  useful 
in  the  wrist  in  the  adult,  care  must  be  taken  not  to  cause  sloughing 
of  the  tendons  later  on  by  too  vigorous  use  of  the  retractors,  as 
their  blood-supply  is  already  impaired  by  the  disease  of  their 
sheaths. 

If  a  single  dorsal  incision  be  made  use  of,  the  best  is  that  of  Von 
Langenbeck.  The  following  account  is  taken  from  Stimson  :  f  The 
hand  is  bent  toward  the  inner  side,  and  an  incision  is  begun  at  the 
ulnar  border  of  the  second  metacarpal  bone  and  carried  upwards 
on  to  the  radius  for  4  inches,  crossing  the  ulnar  edge  of  the  tendon  of 
the  extensor  carpi  radialis  brevior  where  it  is  inserted  into  the  base 
of  the  third  metacarpal  bone,  and  splitting  the  dorsal  ligament  of 
the  wrist  exactly  between  the  tendons  of  the  extensor  secundi  in- 
ternodii  and  extensor  of  the  forefinger.  This  incision  should  be 
carried  down  to  the  bone,  and  the  soft  parts  detached  on  the  radial 
side  with  an  elevator ;  the  tendons  of  thumb  and  fingers,  where 
they  lie  in  the  grooves,  are  raised  bodily  with  the  periosteum,  and 
their  sheaths  are  not  opened. 

The  hand  is  flexed  so  as  to  make  the  first  row  of  carpal  bones 
present  in  the  wound  ;  the  scaphoid  is  separated  from  the  trapezium 
and  taken  out;  then  the  semilunar  and  cuneiform,  the  interosseous 
ligaments  being  cut,  and  the  bones  prised  out  with  a  small  eleva- 
tor.    The  trapezium  and  pisiform  are  left  if  possible. 

To  take  out  the  second  row  the  operator  steadies  the  rounded 
articular  extremity  of  the  os  magnum  with  the  fingers  of  his  left 

*  In  the  very  young,  when  disease  occurs  in  this  joint,  which  is  very  rare,  exten- 
sive scooping  out  of  carious  bones  and  scraping  out  of  sinuses  may  be  undertaken, 
although  no  set  operation  can  be  done,  owing  to  the  tiny  size  of  the  parts.  In  1877 
I  removed  five  of  the  carpal  bones  by  a  single  dorsal  incision  in  an  infant  aged  two 
years  and  a  half,  a  patient  of  Dr.  T.  Eastes,  of  Folkestone,  tlie  sinuses  present  being 
thoroughly  scraped  out  witii  a  sharp  spoon.  The  result  was  most  satisfactory  botli 
as  to  tlie  permanency  of  tlie  cure  and  the  usefulness  of  the  fingers. 

t   Operative  Surgery,  p.  163. 


EXCISION    OF   THE    WRIST.  47 

hand,  and,  while  an  assistant  abducts  the  thumb,  he  divides  with  a 
knife  the  connection  between  the  trapezium  and  trapezoid,  passes 
the  knife  into  the  carpo-metacarpal  joints,  and  into  the  ligaments 
on  the  dorsal  side  of  the  ends  of  the  metacarpal  bones,  while  an 
assistant  strongly  flexes  them;  in  this  way  the  trapezoid,  os  mag- 
num, and  cuneiform  can  be  brought  out  together. 

The  ends  of  the  radius  and  ulna  are  next  protruded,  and  the  dis 
eased  portions  removed. 

In  this,  as  in  Sir  J.  Lister's,  or  any  excision  of  the  wrist,  ^reat 
care  must  be  taken  not  to  open  the  radial  artery,  not  to  interfere 
with  the  palmar  surface  more  than  can  be  helped,  to  preserve  any 
sound  though  inflamed  periosteum,  not  to  damage  the  tendons* 
with  retractors,  etc.,  and  finally  to  adopt  early,  and  to  persevere  with, 
movements  of  the  fingers. 

Excision  of  the  Wrist  for  Injury. — This  will  be  still  more 
rarely  required.  Mr.  Pye  {Med.  Times  and  Gaz.,  1879,  vol.  ii.  p.  582) 
has  published  a  case  of  compound  dislocation  in  an  adult.  Some 
bones  were  protruding  through  a  transverse  rent  on  the  front  of  the 
wrist,  the  radial  artery  was  uninjured,  the  ulnar  could  not  be  felt. 
The  flexor  carpi  radialis  and  flexor  longus  pollicis  were  torn  across. 
The  ends  of  the  radius  and  ulna  were  sawn  off  and  the  carj)al  bones 
removed,  piecemeal,  until  only  the  trapezium  and  the  distal  part 
of  the  OS  magnum,  which  was  apparently  uninjured,  were  left. 
Strict  antiseptic  precautions  were  taken,  and  the  wound  healed 
rapidly.  There  was  a  steady  regain  of  power  in  the  wrist  and  hand, 
the  patient  being  again  able  to  carry  his  milk-pails.f 

Excision  of  Wrist  for  Gunshot  Injury.— Dr  OtisJ  states  that 
ninety-six  cases  of  excision  of  the  wrist,  varying  much  in  extent, 
were  returned.  Six  of  these  were  complete,  and  five  recovered  with 
the  functions  of  the  hand  much  impaired,  but,  all  things  taken  into 
consideration,  in  a  better  condition  than  if  they  had  been  submitted 
to  amputation.  In  the  ninety  partial  excisions,  ankylosis  and 
extreme  deformity  appear  to  have  been  common.     Generally,  the 


*  If  any  of  the  tendons  are  unavoidably  so  interfered  with  that  a  portion  is 
likely  to  slough,  it  might,  perhaps,  be  well  to  cut  out  this  part,  and  unite  the  ends 
with  a  carbolized  silk  suture.  And  wliere  sucii  manipulation  of  a  tendon  is  un- 
avoidable, it  would  be  better  to  divide  it,  and  unite  it  subsequently. 

t  Sir  AV.  MacCormac  {Bub.  Quart.  Journ.  Med.  Sci.,  1867,  p.  281)  publislies  the 
case  of  a  girl,  aged  ten,  in  whom  he  removed  the  whole  of  the  left  carpus  and  most 
of  the  metacarpal,  for  a  machinery  accident,  the  patient  recovering  with  a  useful. 
limb. 

X  Med.  and  Surg.  Hist,  of  the   War  of  the  Rebellion,  part  ii.  p.  999  et  seq. 


48  OPEEATIONS    ON    THE    UPPER    EXTREMITY. 

hand  was  strongly  deflected  to  the  radial  side  *  the  fingers  rigidly 
fixed,  the  skin  over  the  projecting  end  of  the  ulna  irritable  and  ex- 
posed to  injury.  "With  our  present  experience  of  excisions  of  the 
wrist  for  injury,  it  seems  probable  that  recovery  unattended  by 
ankylosis  is  seldom  to  be  anticipated,  yet  that  this  result  is  not  dis- 
astrous, provided  the  hand  is  in  good  position  and  the  functions  of 
the  fingers  are  in  some  degree  preserved."  In  a  very  few,  loose, 
flail-like  joints  were  observed,  remediable  by  apparatus.  Finally, 
Dr.  Otis  concludes  by  saying  that  the  "  question  whether  the  wrist- 
joint,  from  its  complexity,  is  altogether  unfitted  for  the  favor- 
able performance  of  excision  for  injury  is  still  not  full}^  eluci- 
dated." 

The  chief  English  authority.  Sir  T.  Longmore,  writes  thus  on  this 
operation  tf  "  Gunshot  wounds  of  the  wrist  are  usually  attended 
with  so  much  injury  to  the  tendons  and  other  structures  surround- 
ing the  joint  that  it  is  scarcely  possible  in  such  cases  for  the  opera- 
tion of  resection  to  produce  satisfactory  results.  Just  as  extensive 
laceration  of  the  forearm,  by  destroying  the  motor  power,  renders 
the  hand  useless,  so  does  destruction  of  the  flexor  or  extensor  ten- 
dons, by  which  the  wrist-joint  is  embraced,  effect  the  same  re- 
sult." 

Causes  of  Failure  after  Excision  of  the  Wrist.— These  are 
mainly : 

1.  Persistent  sinuses  and  discharge  set  up  by  remaining  caries  or 
necrosis.  Sir  W.  Fergusson  {Path.  Soc.  Trans.,  vol.  viii.  p.  391) 
showed  a  specimen  in  which  all  the  bones  had  been  supposed  to 
have  been  removed  by  a  single  incision  on  the  ulnar  side.  The 
pisiform,  trapezium,  and  part  of  the  unciform  had  been  left.  The 
movement  of  the  fingers  was  good,  but  sinuses  remained  on  both 
sides  communicating  with  a  bare  piece  of  radius.  Death  took  place 
from  phthisis.  Mr.  J.  Hutchinson  {ibid.,  vol.  xvii.  p.  239)  showed 
a  specimen  of  wrist-joint  after  partial  resection  by  Mr.  Stanley. 
Though  no  active  caries  was  present,  discharge  was  kept  up  by  a 
necrosed  bit  of  bone  in  a  cavity  at  the  back  of  the  carpus.  Death 
here  also  took  place  from  chronic  phthisis. 

2.  Matting  and  sloughing  of  tendons,  and  consequent  stiffness  of 
fingers. 

3.  Phthisis. 

*  As  this  appears  to  be  irremediable  by  any  apparatus,  Dr.  Otis  suggests  that  it 
should  be  met  by  always  reuioving  the  carpal  end  of  the  ulna  at  the  same  level 
with  the  section  of  the  radius,  whenever  it  is  necessary  to  remove  the  lower  end  of 
the  latter. 

t  Syst.  of  Surg.,  vol.  i.  p.  552. 


AMPUTATION    AT    THE    WRIST.  49 

AMPUTATION  THROUGH  THE  WRIST-JOINT. 

The  value  of  this  operation  has  been  a  good  deal  disputed.  It 
has  been  thought  by  some*  "  that  it  possesses  no  particular  advan- 
tage ;  the  length  of  the  stump  is  of  no  great  consequence ;  the 
flaps,  with  the  numerous  tendons  in  them,  may  not  heal  readily." 
Otherst  have  gone  farther,  and  said  that  the  long  stump  is  found 
by  instrument  makers  difficult  to  fit  with  an  artificial  hand!  That 
this  is  certainly  not  always  the  case  is  shown  by  Mr.  H.  Bigg,J 
from  two  cases,  one  a  Commander  R.N.,  the  other  an  artisan  in 
the  Woolwich  Arsenal,  both  of  whom,  after  being  fitted  Avith  artifi- 
cial hands,  were  able  to  engage  actively  in  their  respective  em- 
ployments. 

As  the  above  objections  are  scarcely  sufficient,  and  as  this  ampu- 
tation preserves,  if  the  parts  heal  quickly,  good  pronation  and 
supination,  it  should  be  practiced  whenever  opportunities  arise. 
These,  however,  as  is  shown  below,  will  not  be  numerous. 

Indications. 

1.  Extensive  injuries  (gunshot  and  otherwise)  of  a  hand  not  ad- 
mitting of  the. preservation  of  any  fingers,  and  in  which  the  damage 
of  soft  parts  does  not  necessitate  amputating  through  the  forearm. 

2.  Disease  of  carpus  locally  too  far  advanced  for  excision,  or 
rendered  by  age,  condition  of  health,  etc.,  inappropriate  for  excision. 

3.  Cases  of  failed  excision. 

But  in  carpus  disease  the  soft  parts  are  often  so  mucli  damaged 
by  sinus  formation  and  other  results  of  the  disease  that  the  surgeon 
is  driven  to  amputate  higher  up ;  and  where  this  may  not  be  the 
case,  the  articular  surfaces  of  the  radius  and  ulna,  owing  to  disease, 
have  to  be  removed,  the  operation  thus  ceasing  to  be  correctly  am- 
putation through  the  wrist-joint. 

4.  5,  and  6.  More  rarely  still,  for  the  results  of  palmar  suppura- 
tion, gangrene,  or  burns. 

Operation^). — As  in  other  amputations  where  the  amount  of 
skin  available  varies  considerably,  several  methods  will  be  given. 
The  first  of  these  is  the  best. 

Different  Methods. 

1.  Long  palmar  tiap  (Figs.  15,  16). 
•  2.  Equal  antero-posterior  flaps. 

3.  Method  of  Dubreuil  (Fig.  16). 

4.  Circular  amputation. 

5.  Long  dorsal  flap,  by  Teale's  method. 

*  Sir  W.  Fergiisson,  Pract.  Surgery,  p.  325. 
t  John  Bell,  Manual  of  Surr/ical  Operations,  p.  53. 
X  Artificial  Limbs  and  Amputations,  p.  <S3. 
4 


50 


OPEIIATIOXS    OX    THE    UPPER    EXTREMITY. 


Fio.  15. 


1.  Amputation  by  a  Long  Palmar  Flap  (Figs.  15  and  16).— 
This  has  the  advantage  of  preserving  skin  thick,  well  used  to  pres- 
sure,  and    abundantly    supplied    with 
blood;    thenerves  are  also  cut  square, 
and  disarticulation  is  easy. 

The  hand  being  supinated  and  the 
wrist  extended,  an  incision  is  made  (on 
the  left  side)  from  the  top  of  the  styloid 
process  of  the  radius  straight  down  well 
on  to  the  thenar  eminence,  and  then, 
curving  across  (about  on  a  line  with  the 
superficial  palmar  arch*),  and  marking 
out  a  well-rounded  flap  by  passing  up- 
Avards  over  the  hypothenar  eminence  to 
the  tip  of  the  styloid  process  of  the  ulna. 
This  flap  is  next  dissected  up  without 
scoring  as  far  as  the  level  of  the  wrist- 
joint;  it  should  contain  on  its  under 
surface  some  of  the  fibres  of  the  thenar  and  hypothenar  muscles. 
If  this  precaution  is  taken,  the  flap  will  contain  the  superficialis 
volte  and  ulnar  arteries,  and  thus  run  no  risk  of  sloughing. 

The  hand  being  now  pronated  and  flexed  at  the  wrist-joint,  an 
incision  is  made  slightly  convex  across  the  wrist  from  one  styloid 
process  to  the  other.  The  palmar  flap  being  now  retracted,  the 
hand  is  strongly  flexed  and  the  joint  opened  ;  the  soft  parts  in  front 
and  behind  are  now  severed  with  a  circular  sweep  (the  assistant 
pulling  slightly  on  the  hand),  the  remaining  ligaments  divided,  and 
the  hand  removed.  If  the  articular  cartilages  of  the  radius  are  dis- 
eased, they  must  be  dealt  with  either  by  gouging  or,  if  necessary, 
by  a  clean  section  above  the  articular  cartilage,  a  step  which  will 
interfere  with  free  pronation  and  supination  later  on.  The  apices 
of  the  styloid  processes  should,  in  any  case,  be  removed,  but  the 
base  of  that  of  the  radius  should  always  be  left,  if  possible,  to  secure 
the  action  of  the  supinator  longus. 

The  radial,  ulnar,  the  two  interosseous,  and  the  superficialis  volse 
arteries  will  probably  need  securing.  Any  sinuses  are  now  scraped 
out  with  sharp  spoons  and  the  tendons  trimmed.  From  the  facility 
with  which  these  last  slip  up  into  their  sheaths,  antiseptic  precau- 
tions should  be  carefully  taken. 

Another  Method. — This  consists  of  marking  out  the  palmar 
flap  (but  not  dissecting  it  up),  opening  the  joint  by  a  dorsal  incision 


*  This  level  is  usually  low  enough.  If  the  parts  on  the  dorsum  are  damaged,  the 
paJmar  incision  may  be  made  longer.  Mr.  Barwell  British  Medical  Journal,  August 
30,  1873)  advises  bringing  the  incision  as  low  as  the  crease  in  the  palm,  which  is 
due  to  flexion  of  the  fingers. 


AMPUTATION    AT    THE    WRIST.  51 

as  above  given,  and  then  cutting  the  palmar  flap  by  transfixion,  the 
knife  being  passed  behind  the  bones.  As  in  this  method  it  is  diffi- 
cult not  to  hitch  the  knife  on  the  pisiform  and  unciform  bones,  and 
to  avoid  a  jagged  edge  to  the  palmar  flap,  and  as  the  flexor  tendons, 
being  relaxed,  are  pulled  out  by  the  knife 
instead   of   being   cut   cleanly,    I    do    not  Fig.  16. 

recommend  it. 

2.  Amputation  by  Equal  Antero- 
posterior Flaps. — The  surgeon  may  be 
obliged,  where  the  soft  parts  are  scanty,  to 
make  use  of  this  method.  The  objections 
to  it  are  that  if  the  tissues  are  thin  there  is 
some  risk  that  the  cicatrix  may  be  adhe- 
rent to  the  bones,  and  that  these  will  be  but  poorly  covered.  Dur- 
ing healing  the  drainage  is  less  satisfactory. 

3.  Amputation  at  the  Wrist  by  the  Method  of  Du- 
breuil*  (Fig.  16). — In  a  few  rare  cases,  e.g.,  where  the  soft  parts 
on  the  back  and  front  of  the  wrist  are  much  damaged,  perforated 
by  sinuses,  etc.,  this  ingenious  method  may  be  made  use  of. 

The  hand  being  pronated,  the  surgeon  commences,  at  a  point  at 
the  junction  of  the  outer  with  the  middle  third  of  the  back  of  the 
forearm,  a  little  below  the  level  of  the  wrist-joint,  a  convex  incision, 
which  reaches  at  its  summit  the  middle  of  the  dorsal  surface  of  the 
thumb,  and  terminates  in  front,  just  below  the  palmar  aspect  of  the 
wrist,  at  the  junction  of  the  outer  with  the  middle  thirds  of  the 
forearm.  The  flap,  consisting  of  skin  and  fascise,  having  been 
raised,  the  two  ends  of  its  base  are  joined  by  an  incision  at  a  right 
angle  to  the  long  axis  of  the  forearm.  Finally,  disarticulation  is 
performed,  beginning  at  the  radial  side. 

4.  Circular  Amputation  at  Wrist.— This  method  is  only 
suited  to  patients  with  thin,  lax  skins,  and  even  in  them  it  is  often 
difficult  to  raise  quickl}'  and  neatly  the  skin,  which  is  here  adherent 
to  some  of  the  adjacent  parts,  as  at  the  base  of  the  hypothenar  emi- 
nence. Moreover,  cutting  through  these  thin,  lax  skins  may  be 
followed  by  sloughing,  especially  if  their  vitality  is  impaired  by 
sinuses,  etc. 

The  hand  being  supported  by  an  assistant,  the  surgeon  draws  up 
the  skin  of  the  forearm,  and  makes  his  first  circular  incision  through 
the  skin  on  a  level  with  the  carpo-metacarpal  joints  of  the  little 
finger  and  thumb,  encroaching  thus  upon  the  thenar  and  hypo- 
thenar eminences,  an  inch  or  an  inch  and  a  quarter  below  the  sty- 
loid processes.  The  skin  being  retracted  by  freeing  the  soft  parts 
with  light  touches  of  the  knife,  another  circular  sweep  is  made  just 

*  Precis  d' Operations  <le  Chiruryie,  p  ir  le  Dr.  J.  Chauvel,  p.  171. 


52  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

above  the  level  of  the  pisiform  hone,  so  as  to  sever  cleanly  the 
numerous  tendons,  together  with  the  vessels  and  nerves.  The  joint 
is  then  opened  and  the  styloid  processes  removed. 

5.  Amputation  of  Wrist  by  Long  Dorsal  Flap, — This 
method  on  Mr.  Teale's  principle  is  not  to  be  recommended.  If  a 
skin-flap  alone  were  taken,  its  poor  vitality  would  probably  end  in 
sloughing,  while,  if  the  tendons  are  taken  up  as  well,  but  little  addi- 
tional vascularity  is  gained,  while  the  flap  is  inevitably  somewhat 
ragged. 

LIGATURE  OF  RADIAL  ARTERY  ON  THE  BACK  OF 
THE  WRIST*  (Fig.  5). 

Guide. — A  line  drawn  from  a  point  just  internal  to  the  apex  of 

the  styloid  process  to  the  back  of  the  first  interosseous  space. 

Relations  :  In  Front. 

Skin,  fascifc;  branches  of  superficial  radial 

vein,  and   of  radial  and   musculo-cuta- 

neous  nerves. 

Three  extensor  tendons  of  thumb. 

Kadial  artery 
on  back  of  wrist. 

Outside.  Behind.  Inside, 

V.  comes.      Styloid  process  ;  external  lateral  ligament;     V.  comes, 
trapezium  ;  carpal  ligaments. 

Indications. — Few ;  usualh^  wounds,  e.g.,  by  the  slipping  of  a 
chisel,  by  breaking  crockery,  etc.  In  such  cases  both  endsf  would, 
of  course,  be  secured,  and  the  surgeon  would  examine  as  to  injury 
to  any  of  the  extensor  tendons  (p.  38). 

Operation. — The  incision,  l2-2  inches  long,  may  be  in  the 
above  line  or  parallel  with  the  tendons.  In  either  case  it  should 
be  over  the  lower  part  of  the  vessel,  just  before  it  dips  between  the 
heads  of  the  first  dorsal  interosseous  into  the  palm.  It  should  be 
made  lightly,  so  as  not  to  damage  the  radial  vein  or,  deeper  down, 
the  tendons.  The  radial  vein  being  drawn  aside  with  a  blunt  hook, 
and  the  deep  fascia  being  carefully  opened,  the  tendons  are  pulled 
out  of  the  way  and  the  artery  separated  from  its  veins.  The  liga- 
ture may  be  passed  from  either  side.  If  the  parts  need  relaxing, 
the  hand  should  be  hyper-extended.     All  injury  to  the  closely  con- 


*  Tlie  so-called  "  tabatiere  anatomique,"  a  triangular  space  bounded  externally 
by  the  extensor  ossis  metacarpi  and  extensor  primi  internodii,  internally  by  the 
extensor  secnndi  internodii ;  its  apex  is  formed  by  the  meeting  of  these  tendons, 
and  its  base  by  the  lower  edge  of  the  posterior  annular  ligament  or  base  of  the 
radius. 

f  Mr.  Butcher  (Operative  Surgery,  p.  407)  states  that  the  distal  end  of  the  artery 
is,  after  the  division  of  the  vessel,  difficult  to  find,  owing  to  its  tendency  to  retract. 


LIGATURE    OF    RADIAL.  53 

tigous  tendon-sheaths  must  be  avoided;  and,  for  the  same  reason, 
union  of  the  wound  without  suppuration  is  particularly  indicated 
here. 


.     CHAPTER  III. 
OPERATIONS  ON  THE  FOREARM. 

LIGATURE  OF  RADIAL  IN  THE  FOREARM  (Fig.  17). 

In  the  upper  two  thirds  the  arter}'^  is  sub-muscular ;  in  the  lower 
third  it  is  sub-fascial. 

Line. — From  the  centre  of  the  bend  of  the  elbow  (where  the  ar- 
tery is  given  off  opposite  to  the  neck  of  the  radius)  to  a  point  just 
internal  to  the  styloid  process  of  the  radius. 

Guide. — The  above  line,  and  the  inner  aspect  of  the  supinator 
longus. 

Relations:  In  Front. 

Skin,  fasciffi. 

Branches  of  musculo-cutaneous  nerve,  espe- 
cially below. 
Superficialis  voire  below. 
Transverse^branches  of  venpe  comites. 
Supinator  longus  overlapping. 
Outside.  Inside. 

Supinator  longus.  Pronator  radii  teres. 

Radial  nerve  (middle  third).  Flexor  carpi  radialis. 

Vein.  Vein. 

Radial  artery 
in  forearm. 

Behind. 
Biceps. 

Supinator  brevis. 
Pronator  radii  teres. 
Flexor  sublimis  digitorum. 
Flexor  longus  pollicis. 
Pronatoii  quadratus. 
Radius. 
Indications. 

(1)  Wounds  ;  stabs  ;  cuts  witli  glass,  etc. 

(2)  Traumatic  aneurism. 

In  these  cases,  the  limb  having  been  rendered  evascular  by  Es- 
march's  bandages,  the  surgeon  opens  the  swelling,  turns  out  the 
clot,  and  ligatures  the  artery  above  and  below.     If  he  prefer  it,  he 


54 


OPERATION'S    ON    THE    UPPER    EXTREMITY. 


may  snip  out  the  swelling  an 
Fio.  17. 


In  the  upper  drawing  ligature  of  the 
brachial  in  front  of  the  elbow  is  shown. 
The  biceps  tendon  is  outside  the  artery, 
giving  oft"  in  the  upper  angle  of  the 
wound  the  bicipital  fascia  ;  along  the 
lower  border  of  the  wound  lies  the 
median  nerve. 

The  remaining  drawings  show  liga- 
ture of  the  radial  and  ulnar.  In  the 
lower  two  figures  too  much  of  the  arte- 
ries is  shown. 


d  twist  both  ends  of  the  arter3^  The 
first  method  is,  on  the  whole,  the 
most  generally  applicable. 

(3)  Punctured  wounds  of  palmar 
arch.  Ligature  of  the  radial  and  ul- 
nar is  preferred  by  some,  but  the 
reader  is  referred  to  the  remarks  at 
p.  36. 

A.  Ligature  in  Lower  Third 
of  Forearm  (Fig.  17).— The  hand 
l)eing  completely  supinated  arrd  the 
wrist  extended  at  first,  the  surgeon, 
seated  comfortably,  makes  an  incision 
2  inches  long,  midway  between  the 
tendons  of  the  supinator  longus  and 
flexor  carpi  radialis,  or  (if  there  be 
much  swelling)  exactly  in  the  line  of 
the  artery,  going  lightly*  through 
the  skin  and  subcutaneous  tissue. 
A  large  branch  of  the  radial  vein, 
which  is  usually  met  with  subcuta- 
neous and  just  under  the  incision,  is 
now  drawn  aside  or  divided  between 
two  ligatures.  The  deep  fascia  is  slit 
up  on  a  director,  and  the  Avrist  now 
flexed  to  relax  the  parts.  The  artery 
being  separated  from  the  venee  com- 
ites,t  the  needle  may  be  passed  in 
either  direction.  Damage  to  any  of 
the  tendon-sheaths  should  be  most 
carefully  avoided. 

B.  Ligature  of  Radial  Artery 
in  Midale  Third  of  Forearm. 

Guide. — Line  of  artery,  p.  53. 

Relations,  p.  53.  The  nerve  is 
now  on  the  outer  side  of  the  artery, 
but  not  very  close  to  it. 

The  steps  are  very  much  as  above, 
but  the  artery  is  lying  deeper.     The 


*  So  as  to  avoid  tlie  radial  vein,  which  always,  and  the  siiperfieialis  volfe,  whicii 
sometimes,  lie  superficial  here,  just  under  the  deep  fascia,  which  is  very  thin.  On 
the  dead  subject,  especially,  it  is  easy  for  the  student  to  get  down  to  or  below  the 
artery  with  his  first  incision. 

t  These,  owing  to  the  free  collateral  venous  currents,  may  be  tied  in  if  it  is  found 
very  difficult  to  separate  them  from  tiie  artery. 


LIGATUEE    OF    ULNAR.  55 

incision  over  the  middle  third  of  the  artery  should  be  fully  two 
inches  long,  the  parts  well  relaxed  when  the  deep  fascia  is  opened, 
the  inner  aspect  of  the  supinator  longus  must  be  defined,  and  this 
muscle  drawn  well  outwards.  The  needle  must  be  passed  from 
without  inwards. 

C.  Ligature  of  Eadial  Artery  in  Upper  Third  of  Fore- 
arm (Fig.  17). 

Guide. — Line  of  artery,  and  inner  aspect  of  supinator  longus. 

Relations,  p.  53. — The  nerve  is  on  the  outer  side,  but  well  re- 
moved from  the  artery.  The  vessel  itself  lies  somewhat  obliqueh^ 
as  it  passes  from  the  middle  of  the  elbow  triangle  to  the  outer  side 
of  the  forearm. 

In  a  muscular  arm  it  is  very  easy  to  get  into  difficulties  by  not 
hitting  off  the  right  inter-muscular  septum,  and  thus  getting  too 
near  the  middle  line  of  the  forearm,  unless  the  line  of  the  artery  is 
remembered.  An  incision,  at  least  2j  inches  long,  is  made  over  the 
upper  third  of  the  artery,  in  the  above  line.  Any  branches  of  the 
radial  vein  are  drawn  out  of  the  way,  and  secured  with  catgut  liga- 
tures. The  deep  fascia  is  slit  up  to  the  full  extent  of  the  wound, 
along  a  white  line  which  marks  the  interval  between  the  supinator 
longus  and  pronator  radii  teres.  These  muscles  may  be  known  by 
the  direction  of  their  respective  fibres  (Fig.  17),  the  former  going 
straight  down  along  the  radius,  and  the  latter  obliquely  downwards 
and  ovitwards  to  the  centre  of  this  bone.  The  muscles  being  re- 
laxed by  bending  the  elbow  and  wrist  joints,  and  the  cellular 
interval  between  them  having  been  opened  cleanly  with  a  director, 
they  are  drawn  aside  with  blunt  hooks,  and  the  pulsation  of  the 
vessel  felt  for.  The  venje  comites  having  been  separated,  the  needle 
may  be  passed  from  without  inwards. 

LIGATURE  OP    ULNAR  ARTERY  IN  THE  FORE- 
ARM (Fig.  17). 

Line. — As  this  artery  takes  a  very  oblique  course  inwards  to  the 
ulnar  border  of  the  forearm  before  it  runs  down  parallel  with  this 
border  to  the  wrist,  the  surface-marking  for  the  lower  two-thirds  of 
the  vessel  will  be  a  line  drawn  from  the  front  of  the  internal  con- 
dyle to  the  outer  side  of  the  pisiform  bone. 

Guide. — The  above  line,  and,  in  the  lower  third,  the  outer  asi)ect 
of  the  flexor  carpi  ulnaris. 

Relations  in  Forearm  : 

In  Front. 

Skin  ;  superficial  and  deep  fascia?. 
Branches  of  internal  cutaneous,  ulnar  cutaneous 
nerve,  and  anterior  ulnar  vein. 


56  OPERATIOXS    ON    THE    UPPER    EXTREMITY.  • 

Median  nerve. 

Pronator  radii  teres. 

Flexor  carpi  radialis. 

Palmaris  longus. 

Flexor  digitorum  sublimis. 

Outside.  Inside. 

Flexor  digitorum  sublimis.  Flexor  carpi  ulnaris. 

Vein.  Ulnar  nerve. 


Vein. 


Ulnar  artery 
in  forearm. 


Behind. 
Brachialis  anticus. 
Flexor  profundus  digitorum. 

Indications. — These  are  the  same  as  for  the  radiill,  pp.  53,  54. 
Ligature  of  Ulnar  Artery  in  Lower  Third  of  Forearm 

(Fig.  17). -^Position  of  hand  supinated,  to  begin  with.  An  incision 
two  inches  long,  is  made,  lightly  at  first,  along  the  outer  border  of 
the  flexor  carpi  ulnaris,  the  superficial  veins  avoided,  and  the  deep 
fascia  opened.  The  wrist  is  then  flexed,  the  flexor  carpi  ulnaris 
drawn  gently  inwards,  the  veins  separated  from  the  artery  if  pos- 
sible, and  the  ligature  passed  from  within  outwards  away  from  the 
nerve.  Care  is  to  be  taken  to  avoid  opening  the  sheaths  of  the 
tendons. 

Ligature  of  Ulnar  Artery  in  Middle  Third-^  of  Fore- 
arm (Fig.  17). — The  position  of  the  limb  being  as  before,  an  in- 
cision, quite  3  inches  long  in  a  muscular  arm,  is  made  in  the  above- 
given  line  of  the  artery  over  its  middle  third.  Any  superficial 
veins  being  drawn  aside  or  secured  with  double  ligatures,  and  the 
wound  sponged  dry,  a  white  line,t  which  indicates  the  intermuscu- 
lar septum  between  the  flexor  carpi  ulnaris  and  the  flexor  sublimis, 
is  looked  for.  If  the  incision  is  not  directly  over  this,  the  edges  of 
the  superficial  wound  may  be  carefully  cleared  a  little  to  one  side 
or  the  other  till  the  septum  is  found,  or,  with  the  finger-tip,  the 
sulcus  between  the  above  muscles  may  be  sought  for.  The  deep 
fascia  having  been  slit  up  to  the  full  length  of  the  wound  on  a 
director,  a  muscular  branch  which  will  serve  as  a  guide  to  the 
artery  will  often  be  found  coming  up  in  the  inter-muscular  space. 

m      — — 

*  The  artery  is  only  ligatured  in  its  upper  third  for  woiuids;  it  is  necessary  to 
remember  the  course  of  the  vessel — oblique  from  without  inwards  —and  to  divide 
sufficiently  tlie  superficial  flexors  which  lie  over  it. 

f  This  line  may  be  wanting.  It  is  often  but  little  marked,  and  occasionally 
fatty,  in  the  bodies  of  the  aged. 


EXCISION    OF    RADIUS    OK    ULNA.  57 

The  cellular  tissue  here  l)eing  carefuU}^  torn  through,  the  muscles 
are  relaxed  by  bending  the  wrist  and  elbow;  retractors  are  now 
introduced  well  into  the  Avound,  this  sponged  dry,  and  the  artery 
looked  for.  The  nerve  which  lies  to  the  inner  side,  and  which 
joins  the  artery  at  the  junction  of  the  middle  and  upper  thirds  of 
the  forearm,  may  be  seen  first.  The  artery  being  cleared,  and  the 
venae  comites  separated  from  it,  the  ligature  is  passed  from  within 
outwards. 

This  is  the  only  ligature  in  the  forearm  which  will  give  trouble 
in  the  dead  subject  owing  to  the  depth,  and  sometimes  the  difficulty 
of  hitting  off  the  intermuscular  septum.  Being  frequent!}''  set  as 
an  examination  test,  the  operation  should  be  carefully  studied  by 
those  at  work  on  the  dead  body. 

DifiQcuIties  and  Mistakes. 

1.  Depth  of  the  vessel  in  a  well-developed  limb. 

2.  jMaking  the  incision  too  short,  or  too  much  to  the  inner  or  the 
outer  side,  and  thus  finding  a  wrong  septum,  e.g.,  one  between  the 
flexor  carpi  ulnaris  and  the  flexor  digitorum  profundus,  or  that 
between  the  flexor  digitorum  subiimis  and  the  palmaris  longus. 

Aids. 

1.  Keeping  carefully  to  the  above-given  line. 

2.  Hitting  off  the  right  intermuscular  sejDtum  and  corresponding 
sulcus. 

3.  Finding  a  muscular  branch,  and  using  it  as  a  guide  to  the 
artery. 

If  a  wrong  space  is  much  opened  w\)  in  the  living  subject,  the 
contiguous  muscles  should  be  brought  together  with  chromic  cat- 
gut sutures  cut  short,  due  drainage  being  provided. 

EXCISION  OF  RADIUS  OR  ULNA. 

Indications. — CI)  Sequestra;  (2)  Compound  fractures;  (3)  New 
growths,  especially  myeloid.  It  is  only  in  the  last  class  of  cases 
that  any  special  difficulty  will  occur,  and  it  is  to  these,  accordingly, 
that  the  following  account  applies. 

Operation  for  Removal  of  Radius.— This  is  the  bone  of 

the  forearm  in  which  myeloid  sarcomata  usually  originate.  The 
following  is  taken  from  a  most  successful  case  by  Mr.  H.  Morris,* 
in  which  he  removed  the  radius  and  ulna  extensively,  for  a  mye- 
loid growth  originating  in  the  former,  and  firmly  attaching  the 
ulna  to  it.  Esmarch's  bandage  being  applied,  a  long  incision  was 
made  over  the  outer  side  of  the  radius,  from  the  styloid  process 
to  the  upper  third.     The  radial  nerve  was  used  as  a  guide  to  the 

*  Clin.  Sac.  Trans.,  vol.  x.  p.  138. 


58  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

interval  between  the  supinator  longus  and  extensor  carpi  radialis 
longior,  Mr.  Morris  having  found  on  the  dead  subject  that  he  could 
most  readily  separate  the  soft  structures  from  the  front  and  back  of 
the  radius  by  going  between  those  muscles,  and  keeping  the  supi- 
nator to  the  fore  part  of  the  incision.  The  supinator  longus  and 
pronator  teres  at  their  insertions  being  detaclied  from  the  radius, 
the  bone,  when  freed  of  its  muscles  in  front  and  behind,  was  sawn 
through  at  the  lower  edge  of  the  supinator  brevis.  A  second  lon- 
gitudinal incision,  of  less  extent  than  the  first,  was  made  along  the 
inner  side  of  the  ulna  from  the  wrist-joint  upwards,  and  through  it 
the  rest  of  the  soft  parts  separated  from  the  tumor  and  ulna.  This 
bone  was  sawn  between  3  and  4  inches  above  the  wrist,  and  the 
lower  ends  of  both  bones  disarticulated  by  opening  the  wrist-joint 
on  the  inner  side.  The  entire  tumor,  with  the  ulna  and  pronator 
quadratus,  was  then  removed  e?i  masse.  The  anterior  interosseous 
artery  was  divided  just  above  the  pronator  quadratus,  but  no  other 
large  branches  were  injured.  The  wounds  healed  in  about  seven 
weeks.  As  soon  as  a  light  leather  splint  was  moulded  on  to  the 
forearm  and  wrist,  the  usefulness  of  the  hand  steadily  increased. 
Four  3^ears  later  Mr.  Morris  brought  the  patient  before  the  Clinical 
Society  {Trans. ^  vol.  xiii.  p.  155,  pi.  vi.).  The  following  was  her 
condition  :  There  was  no  sign  of  recurrence.  By  the  aid  of  a 
simple  leather  splint,  the  patient  was  able  to  nurse,  dress,  carry, 
and  wash  and  care  for  her  children,  do  her  ordinary  household 
work,  and  wash  the  house-linen.  She  could  also  stitch  and  darn, 
and  pick  up  a  pin.  Latterly,  since  contraction  has  taken  place,  she 
could  hold  her  hand  out  straight  without  any  support.* 

Operation  for  Removal  of  Ulna.— In  the  very  much  rarer 
cases  of  myeloid  tumors  springing  from  the  ulna,  the  following  may 
be  the  course  adopted.  The  account  is  taken  from  a  paper  by  Mr. 
Lucas  (Clin.  Soc.  Trans.,  vol.  x.  p.  135).  A  longitudinal  incision, 
about  4  inches  long,  exposed  the  tumor  between  the  flexor  and  ex- 
tensor carpi  ulnaris.  In  making  this  the  dorsal  branch  of  the  ulnar 
nerve  was  divided.  The  soft  parts  being  next  retracted,  the  bone 
was  exposed  above  the  level  of  the  tumor,  and  sawn  through.  The 
piece  connected  with  the  tumor  was  next  drawn  out  of  the  wound, 
while  the  interosseous  membrane  was  divided,  and  the  extensor 
indicis  on  the  posterior  and  the  pronator  quadratus  on  the  anterior 
separated  from  the  tumor.  The  removal  was  completed  b}'^  divid- 
ing the  ligaments  of  the  lower  radio-ulnar  joint,  the  attachment  of 
the  triangular  fibro-cartilage  to  the  ulna  and  the  internal  lateral 

*  After  these  operations,  as  in  any  in  wliich  the  flexors  and  extensors  of  the 
fingers  must,  of  necessity,  be  meddled  with,  passive  movement  of  the  finger  should 
be  commenced  very  early,  and  energetically  persevered  with. 


EXCISION    OF    RADIUS    AND    ULNA.  59 

ligament.  The  patient  left  the  hospital  in  five  weeks,  the  resulting 
usefulness  being  excellent. 

Excision  of  Radius  and  Ulna  in  Military  Surgery.— 

By  this  is  meant  deliberate  removal  of  portions  of  these  bones 
damaged  by  gunshot  or  other  injuries,  not  the  mere  picking  away 
of  spicula  and  fragments. 

Dr.  Otis*  divides  the  cases  into  the  three  groups  of  primary,  in- 
termediary (before  the  thirtieth  day),  and  secondary  (after  the 
thirtieth  day).  Though  caries  and  attempt  at  repair  were  met 
with  in  these  latter  cases,  there  Avas  no  time  for  invagination  of 
sequestra.  Thus  they  were  very  diflterent  from  necrosis  operations, 
and  hence,  in  great  measure,  the  high  mortality.  Of  the  primary 
10  per  cent.,  of  the  intermediary  19  per  cent.,  ended  fatally  ;  the 
mortality  of  the  secondary  was  nearly  as  high  as  that  of  the  primary 
excisions. 

The  concluding  observations  of  Dr.  Otis  are  worthy  of  the  most 
careful  attention  of  military  and  naval  surgeons. 

"  Of  this  large  number  of  excisions  in  the  continuity  of  the  fore- 
arm there  is  little  to  remark  save  that,  in  the  aggregate,  the  mor- 
tality of  shot  fractures  of  the  bones  of  the  forearm  appears  to  have 
been  sensibly  augmented  b}^  operative  interference,  and  that  I  have 
sought  in  vain  for  a  single  instance  in  which  a  formal  excision  of  a 
portion  of  the  shaft  of  either  radius  or  ulna  had  a  really  satisfactory 
result  as  regards  the  functional  utility  of  the  limb.  The  represen- 
tations of  Baudens  of  his  Algerian  experience  led  the  German  sur- 
geons to  practice  these  excisions  in  the  shafts  of  long  bones  to  some 
extent  in  the  Danish  and  Austrian  campaigns,  with  very  unsatis- 
factory results.  Similar  operations  were  resorted  to  with  compara- 
tive frequency  during  the  American  War,  and  the  results  plainly 
indicate,  I  think,  that  formal  primary  operations  of  this  nature 
should  be  banished  from  the  practice  of  military  surgery.  It  is 
bad  enough  to  remove  adherent  primary  sequestra,  for  our  museum 
abounds  in  examples  where  such  fragments  have  retained  their 
vitality,  and  maintained  the  continuity  of  long  bones;  it  is  worse 
to  deliberately  remove  unoffending  healthy  portions  of  the  bone. 
The  mortality  greatly  exceeding  that  of  the  expectant  conservative 
treatment,  the  numerous  consecutive  amputations,  and  the  large 
proportion  of  hopelessly  deformed  limbs  sufficiently  condemn  such 
operations.  I  have  found  nothing  in  the  reports  of  surgery  of  the 
late  Franco-German  War  that  was  not  conformable  to  these  con- 
clusions." 

Sir  T.   Longmoref  brings  the  following  striking  experience  to 

*  nfed.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  pt.  ii.  p.  935  et  seq. 
t  Syst.  of  Surg.,  vol.  i.  p.  544. 


60  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

bear  on  these  cases  :  "  I  have  seen  many  of  these  fractures  in  which 
primary  resection  of  a  portion  of  the  entire  shaft  by  a  shot  has 
occurred,  and  have  not  met  with  bony  union  in  any  case  where  the 
gap  was  a  full  inch  in  amount." 
Causes  of  these  Resections  doing  111  or  Failing. 

1.  Osteo-myelitis. 

2.  Pyaemia. 

3.  Hectic. 

4.  Haemorrhage. 

5.  Painful  irritable  cicatrices. 

6.  Non-union.     False  joint.     Flail-like  limb. 

7.  Displacement  of  the  hand  at  the  wrist. 

8.  Permanent  contraction  of  flexor  or  extensor  tendons. 

AMPUTATION  OF  FOREARM  (Figs.  18,  19,  20). 

Practical  Anatomical  Points. — In  this  frequently  performed 
operation  the  following  should  be  kept  in  view : 

(«)  The  two  bones  are  not  fixed,  like  those  in  the  leg,  but  mov- 
able. This  mobility  may  prevent  their  being  parallel  when  the 
knife  is  sent  across  in  transfixion,  and  thus  lead  to  penetration  of 
the  interosseous  membrane ;  it  must  also  be  remembered  in  sawing 
the  bones.  Lastly,  on  this  mobility  in  pronation  and  supination 
depends  the  usefulness  of  the  stump,  Avhich  must  therefore  be  left 
as  long  as  possible,  the  bones  being  always,  when  practicable,  sawn 
well  below  the  insertion  of  the  pronator  radii  teres  into  the  middle 
of  the  outer  surface  of  the  radius. 

(/?)  In  the  upper  part  of  the  forearm,  both  in  front  and  behind, 
are  fleshy  bellies;  below,  the  soft  parts  are  increasingly  tendinous. 
Furthermore,  the  anterior  border  of  the  radius  and  the  posterior  of 
the  ulna,  especially  of  the  latter,  are  largely  subcutaneous. 

Different  Methods. 

1.  Skin  flaps,  with  circular  division  of  muscles,  etc. 

2.  Transfixion  flaps. 

3.  Circular. 

4.  Teale's. 

1.  Amputation  of  Forearm  by  Skin  Flaps,  with  Circu- 
lar Division  of  Muscles,  etc.  (Figs.  18,  19). — While,  in  an  ampu- 
tation so  often  called  for,  it  is  well  to  practice  several  methods,  none, 
on  the  whole,  answer  so  well  as  this,  for  the  following  reasons :  («) 
By  cutting  one  flap  a  little  longer  than  the  other,  sufficient  skin 
can  always  be  obtained  to  give  a  good  stump.  (/?)  Transfixion, 
while  quite  unsuited  to  the  lower  third,  owing  to  the  numerous 
tendons,  can  only  be  performed  in  the  upper  third  in  moderately 


AMPUTATION   OF   THE    FOREARM. 


61 


in  a  bulky, 


Fig.  18. 


muscular  forearms  with  ultimate  satisfaction.  For 
fleshy  limb  (as  in  a  case  of  accident  in  a  male  adult)  it  is  not  eas}' 
always  to  cut  the  skin  longer  than 
the  muscles  in  bringing  out  the 
knife,  and  so  to  prevent  the  ten- 
dency of  the  fleshy  bellies  to  pro- 
trude while  the  flaps  are  being 
united ;  and  a  little  later,  these 
muscles,  with  large  surfaces  cut 
obliquely,  give  rise  to  a  good  deal  of 
blood-stained  oozing,  which  is  very 
likely  to  cause  tension,  suppuration,  and  delay  in  healing. 

The  brachial  being  secured  with  an  Esmarch's  bandage,  the  arm 
extended  from  the  side,  with  the  forearm  pronated  and  tlie  hand 
steadied  by  an  assistant,  the  surgeon,  standing  outside  the  limb  on 
the  right,  and  inside  it  in  the  case  of  the  left  side,  places  his  left 
index  and  thumb  on  the  borders  of  the  radius  and  ulna,  at  the  spot 
where  he  intends  to  saw  the  bones  (Fig.  18).     The  point  of  a  nar- 


FiG.  19. 


row-bladed  knife  (about  4  inches  long),  or  a  small  catlin,  is  then 
inserted  just  below  the  index,  carried  along  the  bone  for  3  inches, 
and  then  curved  suddenly  across,  so  as  to  mark  out  a  broad  arched, 
not  a  pointed,  flap  (Fig.  19),  and  carried  up  along  the  bone  nearest 
to  the  surgeon  to  a  point  just  below  the  thumb. 

This  flap  is  then  dissected  up  without  scoring,  consisting  of  skin 
and  fsiscia^.*     The  forearm  is  next  raised  by  the  assistant  holding 


*  Tlie  under  surface  of  a  so-called  skin  flap  should  always,  when  possible,  show 
a  few  muscular  fibres ;  this  shows  that  the  deep  fascia  is  present,  in  which  the 
vessels  run  down  to  send  up  branches  to  supply  the  skin. 


62  OPERATIONS  OX    THE   UPPER    EXTREMITY. 

the  hand,  so  that  its  palmar  aspect  faces  the  surgeon  *  who  cuts  a 
similar  flap  from  the  anterior  surface,  but  one  only  about  2  inches 
in  length.  The  flaps  being  retracted,  the  soft  parts  are  divided  with 
a  circular  sweep  close  to  the  base  of  the  flaps,  this  being  repeated 
once  or  twice  till  the  bones  are  quite  exposed.  The  knife  is  then 
passed  between  the  bones,  so  as  to  divide  the  interosseous  mem- 
brane, and  the  periosteum  next  cleanly  cut  in  a  circle  where  the 
saw  is  to  pass.  The  bones  are  then  sawn  through,  with  the  following 
precautions  :  The  heel  being  placed  on  the  bones,  it  is  drawn  lightly 
but  firmly  towards  the  operator  two  or  three  times,  so  as  to  make  a 
groove.  With  a  series  of  light  sweeps,  in  which  the  whole  length 
of  the  saw  is  used,  the  two  bones  are  then  cut  through  together,! 
the  limb  being  kept  supinated  during  the  use  of  the  saw,  so  as  to 
keep  the  bones  as  parallel  as  possible. 

The  assistant  in  charge  of  the  lower  part  of  the  limb  must  be 
most  careful  to  hold  it  steady;  if  he  de^jress  at  all,  the  bones  will 
certainly  splinter  when  half  sawn  through  ;  if,  on  the  other  hand,  he 
raise  the  j^arts,  the  saw  will  be  locked. 

Any  tendons  requiring  it  are  then  trimmed,  and  the  vessels  liga- 
tured or  twisted.  These  are  usually  four — viz.,  the  radial,  under 
cover  of  the  supinator  longus,  close  to  its  bone ;  the  ulnar,  covered 
by  the  flexor  carpi  ulnaris,  on  the  front  of  the  ulna.  Their  respec- 
tive nerves  are  good  guides  to  the  arteries,  save  quite  low  down, 
when  the  radial  has  gone  to  the  back  of  the  limb.  The  anterior 
interosseous  is  found  on  the  front  of  the  interosseous  membrane, 
and  the  posterior  interosseous  between  the  deep  and  superficial 
extensors. 

If  the  surgeon  prefer  it,  instead  of  having  the  forearm  raised  so 
as  to  face  him  while  he  shapes  the  flap  from  the  anterior  or  flexor 
surface,  he  will  tell  the  assistant  to  completely  supinate  the  forearm, 
and  proceed  to  make  the  flap  with  the  limb  in  this  position. 

2.  Amputation  of  Forearm  by  Transfixion  Flaps  (Fig. 
20). — In  the  case  of  a  moderately  muscular  forearm  the  surgeon 
may  make  use  of  this  method  in  amputating  through  the  middle  of 
the  forearm.     For  reasons  already  given  (p.  60),  this  method  is  not 


*  Care  must  be  taken  to  keep  the  bones  parallel  now  and  throughout  the  opera- 
tion. 

f  Some  advise  that  the  more  movable  radius  should  be  divided  before  the  section 
of  the  ulna  is  completed.  If  the  saw  is  used  lightly  and  swiftly,  both  bones  will  be 
sawn  simultaneously.  The  student  usually  commits  these  faults  in  the  use  of  the 
saw — he  bears  too  heavily  on  it,  thus  locking  it  or  fracturing  the  bone,  and  he 
makes  but  short  sweeps,  using  half  of  the  instrument  only. 


AMPUTATION    OF    THE    FOKEAEM. 


63 


(Fergusson.) 


recommended,  but  the  rapidity  with  which  it  can  be  done  recom- 
mends  it   to    the    notice   of 

those  who  may  liave  to  treat  '^^*"     ' 

wounded  in  war  on  a  large 
scale,  or  railway  accidents 
where  more  than  one  limb 
requires  amputation.  The 
limb  being  abducted,  and  the 
forearm  supported  and  pro- 
nated,  with  the  bones  as  par- 
allel as  possible,  the  surgeon, 
standing  outside  the  right 
and  inside  the  left  limb,  lifts 
up  the  soft  parts*  at  the  spot 
where  he  intends  to  saAV  the 
bones,  and  sends  a  narrow- 
bladed  knife  (4  to  5  inches 
long)  across  the  limb,  enter- 
ing it,  and  bringing  it  out 
just  above  the  bones.  He 
then,  by  cutting  downwards  and  forwards,  shapes  as  broad  a  flap 
as  possible  with  a  steady  sawing  movement,  taking  care,  before 
bringing  out  the  knife,  to  cut  the  skin  longer  than  the  muscles  by 
continuing  the  use  of  the  knife  after  the  latter  are  felt  to  be  cut 
through.  The  flap  should  be  3  to  4  inches  long,  according  to  the 
condition  of  the  tissues  on  the  other  surface  of  the  limb,  and  each 
made  as  broad  as  possible  and  bluntly  rounded  as  they  are  finished. 
The  tissues  on  the  front  are  then  lifted  from  the  bones  and  trans- 
fixed by  passing  the  knife  across  immediately  above  the  bones  at 
the  base  of  the  first-made  flap,  the  limb  being  now  supinated.  As 
in  this  second  transfixion  the  skin  on  the  farther  side  of  the  limb 
may  be  punctured,  it  is  well  for  the  surgeon  to  hold  down  its  cut 
edge  with  a  finger.  The  second  flap  is  then  cut,  broad,  well-rounded, 
and  2i  to  3  inches  long  according  to  the  length  of  the  anterior. 
The  flaps  are  then  retracted,  the  soft  parts  severed  with  a  circular 
sweep,  the  interosseous  membrane  divided,  and  the  rest  of  the 
operation  completed  as  in  the  method  first  described  (p.  62). 

A  ver}'  rapid  and  effective  modification  of  the  above  is  the  fol- 
lowing :  As,  owing  to  the  inequality  of  the  soft  parts  on  the  back  as 
compared  with  those  on  the  front  of  the  forearm,  and  also  from  the 
proximity  of  the  ulna  to  the  surface  here,  transfixion  of  a  dorsal 
flap  is  not  always  easy,  a  quicker  method  is  as  follows :  A  skin 
flap,  3J  inches  long,  broad  and  well  rounded,  being  marked  out  on 


*  This  step  is  most  useful— in  fact,  essential.     It  is  often  forgotten. 


64  OPERATIONS    OX    THE    UPPER    EXTREMITY. 

the  posterior  aspect  of  the  limb,  the  knife  is  immediately,  without 
being  taken  off,  pushed  across  in  front  of  the  bones  and  made  to 
cut  a  flap,  by  transfixion,  2j  inches  long,  the  skin  being  cut  longer 
than  the  muscles  (p.  63).  The  dorsal  skin  flap  is  then  dissected  up, 
the  flaps  retracted,  and  the  bones  cleared  as  before. 

3.  Amputation  of  Forearm  by  Circular  Method. — This 
method  is  not  recommended  liere  owing  to  the  flat  shape  of  the 
limb  and  the  adhesion  of  the  deep  fascia  above  to  the  muscles.  It 
may  be  performed  as  follows :  The  surgeon,  standing  outside  the 
limb,  which  is  kept  supinated,  having  drawn  the  skin  well  up- 
wards, passes  a  knife  under  the  forearm,  then  above,  and  so  around 
it  till,  by  dropping  the  point  vertically,  the  back  of  the  knife  looks 
towards  him,  and  its  heel  is  resting  on  the  part  of  the  forearm  which 
is  nearest  to  him.  An  incision  is  then  made  circularly  through 
skin,  superficial  and  deep  fasciffi,*  round  the  whole  circumference 
of  the  limb  2i  inches  below  the  point  where  the  bones  are  to  be 
sawn. 

A  circular  flap  of  tissues  having  been  turned  back  as  high  as  the 
point  of  bone  section,  a  second  and  much  firmer  circular  sweep  is 
here  made  through  everything  down  to  the  bones,  this  being  re- 
peated till  all  the  soft  parts  are  cut  clean  and  square.  If  there  is 
any  doubt  about  the  sufficiency  of  coverings  to  the  bones,  the  soft 
parts  around  these  may  be  freed  a  little  higher  (care  being  taken 
not  to  prick  the  radial  or  ulnar);  the  soft  parts  are  then  vigorously 
and  finally  retracted,  and  the  bones  sawn  through,  with  the  pre- 
cautions given  at  p.  62. 


CHAPTER  IV. 


OPERATIONS  IN  THE  NEIGHBORHOOD  OP  THE 
ELBOW-JOINT. 

AMPUTATION  AT  ELBOW-JOINT  (Fig.  21). 

This  operation  gives  excellent  results,  good  flaps  being  obtain- 
able from  the  thick  soft  parts  in  front  and  from  the  skin  behind, 
which  is  well  used  to  pressure.  Furthermore,  there  are  no  bones  to 
saw. 

It  has  not  been  performed  as  often  as  it  might  have  been,  owing, 

*  If,  in  raising  the  cnfl'like  flap,  muscular  fibres  are  seen  on  the  under  .surface, 
the  presence  of  the  deep  fascia  and,  thus,  a  better  blood  supply  will  be  assured 
than  by  the  quicker  method  of  simply  peeling  the  skin  and  subcutaneous  tissue  off 
the  deep  fascia. 


AMPUTATION    AT    ELBOW- JOINT.  65 

perhaps,  to  the  belief  which  some  surgeons  have  held  that  car- 
tilaginous surfaces  left  in  a  wound  are  a  source  of  delay  in  healing ; 
from  the  fact  that  any  disarticulation,  however  simple,  is  considered 
to  complicate  an  amputation  ;  and  because,  owing  to  the  expanded 
end  of  the  humerus,  the  resulting  Avound  is  somewhat  larger  than 
in  amputation  through  the  lower  third  of  the  humerus. 

Practical  Points. 

(a)  Tlie  internal  condyle  is  nearly  2  inch  below  the  level  of  the 
external. 

(fi)  The  joint  is  opened  most  easily  on  the  outer  side. 

(y)  There  are  masses  of  muscles  on  the  front  and  sides;  of  the 
latter,  those  on  the  outer  side  (owing  to  the  presence  of  the  supinator 
longus)  retract  more  powerfully  than  those  on  the  inner. 

(d)  The  skin  on  the  back  of  ihe  joint  is  well  used  to  pressure,  and 
is  connected  by  fibrous  bands  to  the  back  of  the  ulna. 

Methods.— Owing  to  the  vascularity  of  the  parts,  any  of  the 
following  may  be  made  use  of.  I  would  advise  the  student  to 
practice  the  first  especially. 

i.  Long  anterior  flap  with  short  posterior  (Fig.  21). 

ii.  Lateral  skin  flaps,  or  a  modification  of  this  by  a  single  ex- 
ternal flap. 

iii.  Circular. 

iv.  Long  posterior  flap. 

v.  Long  anterior  flap. 

i.  Long  Anterior  Flap  (usually  by  Transfixion),  with 
Shoi't  Posterior  Flap  (Fig.  21). — This  method  gives  an  excellent 
covering  to  the  front  of  the  humerus,  allows  of  easy  drainage,  and 
preserves  skin  which  is  well  used  to  pressure. 

The  l)rachial  being  controlled  a  little  above  its  centre,*  the  fore- 
arm being  held  somewhat  flexed  and  completely  supinated,  the 
surgeon,  standing  on  the  inner  side  in  the  case  of  the  left,  and  out- 
side the  right  limb,  raises  the  soft  parts  in  front  of  the  elbow  tri- 
angle, and  sends  his  knife,  held  horizontally,  across,  just  in  front  of 
the  joint.  Thus,  entering  it  an  inch  below  the  internal  condyle 
and  bringing  it  out  li  inch  below  the  external  one,  he  cuts  a  well- 
rounded  flap,  3  inches  long,  taking  care,  as  the  knife  emerges,  that 
the  skin  is  cut  longer  than  the  muscles.  Then,  passing  his  knife 
behind  the  limb,  and  looking  over,  the  surgeon  joins  the  two  ends 
of  the  base  of  his  first  incision  by  a  convex  cut  through  the  skin 
over  the  back  of  the  olecranon,  so  as  to  mark  out  a  flap  Ij  inch 
long.      This  is  raised  without  scoring,  care  being  taken  to  keep 

*  The  assistant  who  has  charge  of  the  Esmarch's  bandage,  and  who  is  steadying 
the  arm,  should  draw  the  skin  on  the  haci<  of  the  elbow-joint  somewhat  upwards. 

5 


66 


OPERATIONS  ON  THE  UPPER  EXTREMITY. 


the  knife  towards  the  uhia,  for  fear  of  "button-holes."     The  two 
flaps  being  then  held  back,  any  remaining  structures  in  front  are 

Fig.  21. 


Amputation  through  the  elbow-joint  by  anterior  and  posterior  flaps  at  the  moment  ol 

disarticulation. 

severed,  the  joint  first  opened  on  the  outer  side,  and  the  forearm 
removed  by  dividing  the  lateral  ligaments  and  triceps.* 

During  the  last  steps  the  assistant  in  charge  of  the  forearm  pulls 
this  away  from  the  arm. 

The  brachial  artery  is  next  secured,  together  with  any  other 
vessels  which  continue  to  bleed  on  removal  of  the  Esm arch's 
bandage.  Any  nerves  which  require  it  are  then  cut  short,  a  drain- 
age-tube inserted,  and  the  flaps  carefully  united. 

Modifications  of  the  Above. — The  fla^js  can  be  cut  of  different 
lengths,  according  to  the  state  of  the  soft  parts.  If  the  surgeon  pre- 
fer to  do  so,  he  can  cut  his  anterior  flap  from  without  inwards 
instead  of  by  transfixion,  a  course  which  may  well  be  adopted  in 
an  unusually  bulky,  muscular  limb.  The  posterior  flap  can  be 
made  by  cutting  from  within  outwards,  but  this,  while  quicker,  is 
usually  less  preferable. 

ii.  Amputation  by  Lateral  Skin  Flaps,  or  by  an  Ex- 
ternal Flap. — The  advantages  of  the  lateral-flap  method  are,  that 
it  is  very  easily  done,  and  that,  if  more  skin  is  available  on  one  side 
than  on  the  other,  flaps  unequal  in  length  can  readily  be  made. 


*  In  Fig.  21,  by  mistake,  the  operator  lias  been  shown  commencing  disarticula- 
tion on  the  inner  instead  of  on  the  outer  side,  which  is  usually  the  easier.  The 
flaps  also  are  rather  too  long.     For  these  errors  I  alone  am  responsible. 


EXCISION    OF    ELBOAV-JOINT.  67 

Supposing  the  surgeon  to  be  amputating  by  equal  lateral  flaps — 
standing  as  before,  and  having  his  left  index  finger  on  the  centre 
of  the  elbow  triangle  and  left  thumb  at  the  corresponding  point 
behind,  he  looks  over,  and  enters  his  knife  close  to  his  thumb,  and 
marks  out,  on  the  side  farthest  from  him,  a  flap  well  rounded,  and 
about  2*  or  3  inches  long,  reaching  to  the  finger  in  front.  He  then 
marks  out  a  corresponding  flap  from  this  point,  on  the  side  nearest 
to  him,  to  that  where  he  began.  These  flaps  are  then  dissected  up 
of  skin  and  fasciae  as  thick  as  possible,  the  soft  parts  severed  with  a 
circular  sweep,  and  disarticulation  performed,  beginning  at  the 
outer  side. 

iii.  Circular  Method. — The  surgeon,  standing  as  before,  makes 
a  circular  incision  round  the  forearm,  2*  or  3  inches  below  the 
joint,  going  through  skin  and  fasciae.  A  cuff"  of  skin  is  then  turned 
back  as  far  up  as  the  joint,  the  muscles  severed  with  one  or  two 
firm  sweeps,  the  lateral  ligaments  divided,  and  disarticulation  per- 
formed as  before.  The  edges  of  the  wound  ma}^  be  united  either 
horizontally  from  side  to  side,  or  vertically  from  above  downwards. 


EXCISION  OF  ELBOW  (Figs.  22,  23,  24). 

Practical  Points. — These  bear  upon  the  success  of  this  opera- 
tion. 

(1)  It  is  a  comparatively  simple  joint,  with  small  articular  sur- 
faces readily  got  at.  (2)  Its  synovial  membrane  is  simple.  (3) 
Its  vascular  supply  is  abundant.  (4)  The  surrounding  muscles 
are  powerful,  ensuring,  if  they  regain  firm  attachment,  an  excellent 
range  of  movement.  From  the  above,  and  from  the  untoward 
eff'ects  of  ankylosis,  a  natural  cure  in  the  elboAV  is  often  not  so  use- 
ful as  that  given  by  excision.  This  operation  should  be  performed 
oftener  than  it  is,  especially  in  the  first  six  of  the  following  condi- 
tions. 

Indications. 

1.  Pulpy  disease.  Where  this  has  resisted  treatment  in  a  patient 
who  shows  no  sign  of  tuberculosis,  lardaceous  disease,  etc.,  where  it 
is  the  only  large  joint  affected,  and  where  the  powers  of  repair  are 
sufficient.  If  treatment  fails  to  promise  a  movable  joint,  there  is 
no  good  losing  more  time;  the  muscles  will  only  be  more  wnsted, 
sinuses  will  only  form  more  extensively,  and  the  patient's  health 
be  more  impaired. 

2.  Injury  and  its  results.  (A)  Primary  excision.  When  the  joint 
is  much  opened,  the  cartilages  much  damaged,  when  the  shaft  is 
intact  and  the  tissues  in  h'ont  are  sound.     (B)  Secondary  excision. 


68  OPERATIONS    OX    THE    UPPER    EXTREMITY. 

When  acute  arthritis,  not  yielding  to  incision  and  drainage  of  the 
joint,  has  followed  on  an  injury,  and  ankylosis  is  the  best  result 
which  can  be  hoped  for  without  operation.  In  such  cases,  as  the 
inflamed  condition  of  the  bones  and  soft  parts  may  produce  septic 
cellulitis  and  osteo-myelitis  after  an  operation,  it  will  be  wiser,  be- 
fore excising,  to  wait  till  the  inflammation  has  somewhat  subsided. 
It  must  be  remembered  that,  in  excising  after  injury,  reaction  will 
probably  be  greater,  suppuration  more  certain,  and  a  tendency  to 
bony  ankylosis  more  marked,  especially  if  the  periosteum  is  pre- 
served. 

3.  Ankylosis  in  a  faulty  position.  When  this,  as  the  result  of 
injury  or  disease,  whether  bony  or  densely  fibrous,  renders  the 
limb  useless.  In  deciding  whether  to  excise  for  ankylosis,  the  sur- 
geon should  make  out  how  far  the  limb  is  really  useless,  whether 
there  are  any  cicatricial  bands,  especially  in  front,  and  whether  the 
wasting  of  the  muscles  is  very  marked,  for  these  may  be  so  long 
and  so  utterly  atrophied  that  the  limb  may  he  but  little  more  use- 
ful after  operation. 

4.  Osteo-arthritis.  If  the  patient  is  healthy,  not  advanced  in 
years — i.e.,  not  much  over  forty  and  not  broken  down — and  if  this 
is  the  only  joint  attacked.  The  surgeon  must  be  prepared  for  saw- 
ing very  dense  bones  here. 

5.  Disorganizing  arthritis  of  elbow  after  p3'?emia  or  rheumatic 
fever. 

6.  Unreduced  dislocation  or  fracture  causing  pressure  on  the 
nerve-trunks  near  the  elbow,  especially  if  the  patient  is  young  and 
the  limb  useless. 

Rarer  Indications. 

7.  Mr.  Annandale  (Lancet,  1879,  vol.  i.  p.  251)  has  excised  the 
elbow  two  or  three  times  in  cases  of  extensive  sores  on  the  back  of 
the  joint  in  order  to  allow  the  sore  to  close  by  removing  the  bones 
beneath,  and  to  ensure  movement. 

8.  In  one  case  the  same  surgeon  excised,  with  an  excellent  result, 
Avhere  a  dense  scar  had  formed  on  the  back  of  the  elbow,  drawing 
up  the  forearm  and  fixing  the  joint. 

9.  For  growths  of  the  bones,  especially  if  innocent  and  affecting 
one  bone— e.r/.,  exostosis. 

The  following  points  call  for  consideration  in  any  case  where  ex- 
cision of  the  elbow  is  being  discussed  : 

1.  Age. — This  must  always  have  much  influence.  In  very  young 
children  due  attention  must  be  paid  to  the  naturally  great  power  of 
repair.  After  thirty-five  or  forty  the  surgeon  should  weigh  very 
carefully  all  the  points  of  the  case,  and  only  excise  where  all  else 


EXCISION    OF    ELBOW-JOINT.  69 

is  favorable.     From  puberty*  to  thirty-five  I   consider   the   best 
age. 

2.  CompUcations. — These  are  most  likely  to  present  themselves  in 
the  shape  of  diseases  of  other  bones  and  joints,  for  such  a  complica- 
tion as  phthisis  calls  for  amputation.  Caries  of  the  metacarpal  or 
metatarsal  bones  is  not  of  itself  a  contraindication.  If  diseased 
spine  is  present,  the  question  of  excision  will  depend  on  whether 
the  vertebral  caries  is  old,  or  recent  and  active.  If  old,  is  the  elbow 
a  source  of  much  irritation?  Two  large  joints  are  rarely  diseased 
at  the  same  time.  Mr.  Holmes  {Clin.  Soc.  Trans.,  vol.  i.  p.  143) 
records  a  case  of  a  boy  aged  five  in  which  he  excised,  with  excel- 
lent result,  both  elbow-joints,  only  a  few  weeks  intervening  between 
the  two  operations. 

Mr.  Clement  Lucas  (Brit-  Med.  Journ.,  1881,  vol.  ii.  p.  897)  relates 
a  case  in  which  disease  of  the  left  elbow  came  on  about  two  years 
after  excision  of  the  right  joint,  and  was  also  successfully  operated 
on.  In  1886  I  excised  the  elbow-joint  with  good  result  in  a  London 
lad,  in  whom  three  years  before  I  had  successfully  excised  one 
knee-joint. 

3.  Question  of  the  Value  of  Preserving  the  Periosteum. — Wliile  the 
periosteum  may  be  easily  preserved  in  cases  where  it  is  swollen  and 
loose,  its  preservation  is  in  others  a  matter  of  very  great  difficulty, 
rendering  the  operation  much  more  laborious  and  prolonged,  and 
it  is  extremely  doubtful  if  its  advantages  are  equivalent  in  this 
joint,  where  the  ordinary  operation  gives  such  excellent  results. 

Sub-periosteal  resection  is  said  to  lead  to  less  haemorrhage,  less 
disturbance  of  the  capsule  and  attachments  of  muscles,  and  greater 
completeness  of  the  new  joint.  While  the  last  of  these  is  undoubted,! 
it  may  bring  about  impaired  movement|,  and  I  am  of  opinion  that 
the  surgeon  should  only  trouble  to  preserve  the  periosteum  in 
cases  where  an  unusually  large  amount  of  bone  has  to  be  removed. 
Whenever  the  periosteum  is  preserved,  passive  movement  should 
be  begun  earl3^ 

Operation. — The  single  vertical  incision  at  the  back  gives  such 
excellent  results  that  this  only  will  l)e  described.     The  H-shaped 

*  As  is  stated  below  (p.  73),  young  children  are  not  satisfactory  subjects  for  after- 
treatment  and  movement.  Mr.  Annandale  (loc.  supra  cit.)  has  excised  successfully 
in  patients  aged  three  and  seventy-five.     No  details  are,  however,  given. 

t  In  one  case  Langenbeck  (Arch.,  vol.  viii.  p.  136;  Syd.  Soc.  Bien  Retr.,  1867-8, 
p.  265)  had  "  to  treat  a  dropsy  of  the  new  elbow-joint  b}'  painting  with  iodine,  and 
ultimately  by  the  plaster-of-Paris  bandage." 

X  A  case  is  given  (Langenbeck,  loc.  supra  cit.)  in  which,  after  sub-perir.steal 
resection,  the  condyles  had  been  very  perfectly  reproduced,  and  the  olecranon  had 
been  reformed  to  even  an  inconvenient  extent,  for  it  was  so  long  and  curved  aa 
somewhat  to  limit  extension. 


70 


OPERATIONS  OX  THE  UPPER  EXTREMITY. 


incision,  while  giving  more  free  exposure  and  rendering  the  opera- 
tion more  easy,  has  the  serious  disadvantage  of  damaging  the  inser- 
tion of  the  triceps,  and  of  leaving  additional  scars,  which  may 
hamper  the  movement  of  the  new  joint.  Any  transverse  incision 
should  only  be  added  to  the  longitudinal  when  the  parts  are  ex- 
tremely fixed  and  thickened.  Esmarch's  bandage  having  been 
applied  at  mid-arm,  or  the  whole  liml)  being  rendered  evascular  as 
far  as  the  above  point  by  the  use  of  two  bandages,  a  pillow  is  placed 
under  the  shoulder  of  the  affected  side,  and  the  limb  flexed  and 
carried  over  the  front  of  the  limb  so  as  to  present  it  fairly  to  the 
surgeon,  who  usually  stands  on  the  opposite  side  of  the  body. 

P^iG.  22. 


Excision  (if  the  elbow  by  the  H-shaped  incision.  The  tliickened  soft  parts,  the  sinuses,  the 
carious  ends  of  the  bones,  together  with  the  position  of  tlie  uhiar  nerve,  are  admirably  shown. 
(Fergusson.) 

The  surgeon,  then,  noting  the  relative  position  of  the  condyles 
and  the  course  of  the  ulnar  nerve,  makes  a  straight  incision  of  suffi- 
cient length*  (3  to  4  inches  in  the  adult),  with  its  centre  at  the  tip 
of  the  olecranon,  a  little  internal  to  the  centre  of  the  back  of  the 
joint,  and  parallel  with  the  ulnar  nerve.  This  incision  should  begin 
above  or  below,  as  is  most  convenient,  and  go  down  to  the  bone 
throughout  its  whole  extent,  splitting  the  triceps  muscle  and  ten- 

*  An  insufficient  incision  will  only  inciease  tlie  difficulty  of  the  operation,  and, 
by  the  bruising  then  consequent  upon  the  strenuous  use  of  retractors,  lead  to  sup- 
puration. 


EXCISION    OF    ELBOW-JOINT. 


71 


don.  Partly  with  the  point  of  the  knife,  partly  with  an  elevator  or 
blunt  dissector*  (Fig.  23),  the  surgeon  then  raises,  as  far  as  possible 
in  one  piece  and  without  tearing  or  jagging,  the  outer  half  of  the 
triceps,  Avhich,  with  its  expansion  into  the  deep  fascia  of  the  fore- 
arm over  the  anconeus  (this  latter  muscle  being  taken  up  at  the 
same  time),  is  peeled  up  as  thickly  as  possible  from  its  insertion 
into  the  ulna. 

The  deeper  parts  on  the  outerf  side  of  the  joint  are  then  sepa- 
rated from  the  bones  with  the  point  of  the  knife,  thumb-nail,  and 
blunt  dissector,  until  the  external  condyle  and  head  of  the  radius 
are  completely  exposed.     Next,  the  parts  on  the  inner  side  should 

Fig.  23. 


To  show  the  level  to  which  the  bones  are  to  be  cleared,  and  the  way  in  which 
the  thumb-nail  is  kept  between  the  knife  and  the  soft  parts. 

be  detached  from  the  inner  condyle  and  inner  border  of  the  ole- 
cranon, great  care  being  taken,  by  the  following  precautions,  to 
keep  intact  the  ulnar  nerve :  (a)  By  keeping  the  knife  parallel  with 
the  nerve  and  close  to  the  bone;  (6)  By  the  use  of  the  thumb-nail, 
which  peels  off  the  soft  parts  before  the  knife.  By  these  means 
the  soft  parts  will  be  satisfactorily  cleared  from  the  bones ;  retrac- 
tors, well  applied,  will  be  found  most  useful,  as  the  process  of  peel- 
ing off  the  soft  parts  is  somewhat  fatiguing  to  the  thumb.  This  is 
especially  the  case  in  excision  for  accidents  or  on  tlie  dead  body, 
and  it  is  in  these  only  that  the  nerve  may  be  seen,  though  indis- 


*  The  more  readily  the  periosteum  and  soft  parts  separate,  the  more  will  the 
blunt  instruments  be  used. 

t  For  the  sake  of  practice,  it  is  well  to  take  the  outer  side  first,  before  clearing 
the  inner,  with  the  ulnar  nerve  in  proximity  to  it. 


72 


OPERATIONS    ON    THE    UPPER    EXTREMITY, 


tinctly.  Where  the  parts  have  been  long  inflamed,  they  peel  off 
much  more  readily,  and  the  nerve  is  buried  in  the  swelling. 

The  joint  is  now  strongly  flexed,  the  lateral  ligaments  severed, 
and  the  capsule  opened  just  above  the  olecranon ;  the  bone-ends 
are  then  turned  out  and  prepared  for  the  saw  by  passing  the  knife 
down  to  the  bone,  along  the  lines  of  intended  section,  the  soft  parts 
being  well  retracted  beyond  these  lines. 

Site  of  Bone  Section.* — The  ulna  should  be  sawn  (towards  the 
joint  with  a  small  Butcher's  saw  set  firmly)  so  as  to  remove  the 
greater  and  lesser  sigmoid  cavities  with  the  olecranon.  The  radius 
is  removed  just  below  its  head,  above  the  biceps.  The  section  of 
the  humerus  should  be  through  the  base  of  the  condyles,  so  as  to 
remove  all  the  articular  cartilage.     Any  soft,  caseous  patches  in  the 

Fig.  24. 


To  show  the  application  of  the  saw.    The  dotted  line  across  the  humerus  shows 
that  the  saw  should  pass  well  above  the  articular  cartilage. 

bone-ends  are  now  gouged,  any  possible  sequestra  removed.  In 
very  bad  cases  the  bones  are  very  fatty,  with  little  natural  marrow  ; 
such,  however,  are  not  necessarily  irrecoverable.  If  the  bone  above 
the  levels  of  section  appears  roughened,  and  the  site  of  periostitis, 
this  need  not  be  touched ;  all  will  probably  subside  when  the 
cause  of  irritation  is  removed.  Any  sinuses  should  now  be  laid 
open,  with  due  regard  to  the  ulnar  nerve,  and  their  contents  scraped 
out  with  sharp  spoons.  A  zinc  chloride  solution  (gr.  x-^j)  may  be 
applied  cautiously  if  there  is  any  doubt  about  the  parts  being 
aseptic;  but  any  solution  stronger  than  this  runs  the  risk  of  caus- 
ing sloughing  where  the  vitality  of  parts  is  low.  One  or  two 
points  of  suture  ma}',  perhaps,  be  inserted,  so  as  to  close  just  the 
ends  of  the  wound;  but  all  the  rest  of  this  should  be  left  open, 
and  a  drainage   tube  inserted.     If  the  parts  are  softened   by  in- 


*  See  the  remarks  below  on  the  amount  of  bone  to  be  removed  (p.  74). 


EXCISION  OF  i:lbovv-joint.  73 

flammation,  blistering,  etc.,  or  if  it  is  a  case  of  extensive  disease, 
sutures  had  better  not  be  used.  Very  Varied  forms  of  splint' have 
been  advised.*  Some  surgeons,  to  keep  the  bones  apart,  from  the 
first  put  the  limb  up  on  some  form  of  right-angled  splint;  others, 
fearing  a  flail-like  condition  of  the  joint,  prefer  to  begin  with  the 
arm  and  forearm  on  a  straight  splint,  or  on  one  with  an  obtuse 
angle  (about  135° — Ashhurst,  Encydopxdia  ofSiirgery,  vol.  iv.  p.  477). 
As  ankylosis  is,  in  children  especially,  to  be  dreaded  (vide  infra),  I 
prefer  to  put  cases  up  from  the  first  on  a  right-angled  splint,  using 
some  such  cheap  form  as  that  which  I  have  described  in  the  British 
Medical  Journal,  1877,  vol.  i.  p.  774,  in  which  the  anterior  metal  bar 
supports  the  limb,  while  it  leaves  the  wound  exposed  and  is  easily 
kept  clean,  the  movable  hand-piece  readily  admitting  of  early  pas- 
sive pronation  and  supination. f 

Passive  movement  of  the  fingers  and  hand  should  be  begun  on 
the  second  or  third  day.  The  joint  itself  should  be  moved  as 
soon  as  all  irritation  has  subsided  and  the  deeper  part  of  the 
wound  is  well  healed.|  In  children  an  anaesthetic  may  have  to  be 
given  several  times.  The  angle  of  the  splint  should  be  altered  or 
the  limb  put  up  straight  for  a  few  days,  and  then  flexed.  Later 
on,  weight-extension  should  be  used,  by  securing  a  bag  of  shot, 
which  is  added  to  from  day  to  day.  Later,  the  sound  limb  may 
be  fastened  u^),  so  that  the  child  must  use  the  excised  joint.  This 
getting  children  to  use  the  joint  is  often  most  difficult,  and  friends 
are  often  too  foolish  to  see  that  the  surgeon's  directions  are  carried 
out  daily,  because  they  cause  a  little  short,  but  most  necessary, 
suffering.  Parents  are  far  too  ready  to  think  that  because  an 
operation  has  been  performed,  and  the  wound  nearly,  if  not  quite, 
healed,  no  more  is  necessary. §  In  commencing  pronation  and 
supination  early,  the  ulna  should  be  steadied  while  the  hand  and 
radius  are  very  carefully  moved.  When  the  parts  are  sufficiently 
consolidated,  the  splint  may  l)e  left  off  and  a  sling  substituted. 

*  By  some  surgeons  a  splint  is  here  dispensed  with.  I  strongly  advise  the  use 
of  one  whicli  is  liglit  and  simple  {vide  supra),  especially  in  children,  as  during  the 
first  two  weeks,  where  a  splint  has  been  dispensed  with,  the  bone-ends  have  been 
known  to  project  from  the  wound. 

t  Mr.  Heath's  and  Mr.  Mason's  splints  are  intended  to  aid  in  restoring  the 
movements  of  the  joint,  while  they  also  separate  the  ends  of  the  bones.  Prof. 
Esmarcli's  double-bracketed  splint,  Prof.  Butcher's  box  splint,  and  Prof.  Volk- 
mann's  wire  splint  (based  on  that  for  the  lower  extremity  of  Prof.  Nathan  Smith) 
have  all  been  highly  spoken  of  in  military  surgery. 

X  That  is,  about  the  tenth  day.  The  movements  should  be  practiced  daily,  with 
due  care  and  gentleness. 

^  Pronation  and  supination  in  a  child  are  often  only  apparent,  the  forearm  and 
arm  being  moved  together  from  the  shoulder. 


<4  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

Falls  must  be  carefully  avoided,  and  no  liberties  taken  with  the 
new  union — i.e.,  by  a  patient  attempting  to  do  too  much  with  the 
limb,  as  in  lifting. 

Amount  of  Bone  to  be  Removed. — This  should  be,  roughly 
speaking,  all  the  articular  cartilages,*  including  about  IJ  inch  from 
the  humerus,  and  the  same  from  the  ulna,  the  radius  being  sawn 
through  just  below  its  articular  head.  In  cases  of  ankylosis,t  most 
bone  must  be  removed  from  the  humerus,  that  from  the  bones  of 
the  forearm  being  limited  by  attachment  of  important  muscles. 
Mr.  Annandale  {loc.  supra  clt.)  considers  that  an  interval  of  li  inch 
should  intervene  between  the  bones  after  the  sawn  sections  have 
been  made  and  the  bones  placed  in  the  position  of  extension. 
Certainly,  no  locking  whatever  should  take  place;  H  inch  interval 
is  probably  the  full  amount,  an  interval  of  2  inches  being  liable  to 
lead  to  '"flail  union. "'j 

Mr.  Holmes  has  pointed  out  long  ago  that  if,  after  removing  as 
much  bone  as  is  wise,  disease  is  still  felt  on  the  anterior  surface — 
e.g. T  of  the  ulna —it  is  not  necessary  to  make  further  sections  in 
order  to  get  beyond  it ;  scraping  will  be  sufficient,  and  save  any 
further  interference  Avith  attachment  of  muscles. 

Test  of  Success. — The  movements  should  so  increase  after  the 
first  six  or  eight  weeks  that  within  about  four  months  from  the 
operation  the  patient  should  be  able  to  move  the  new  joint  almost 
as  well  as  the  other,  to  dress  and  feed  himself,  and  to  lift  weights  of 
good  size. 

Repeated  Excision. — This  may  be  occasionally  done  with  suc- 
cess. It  is  of  doubtful  benefit,  and  should  only  be  attempted  when 
the  general  and  local  conditions  are  satisfactory,  not  in  cases  of  per- 
sistent pulpy  disease,  where  this  will  very  likely  be  found  to  have 
passed  out  amongst  the  muscles  of  the  forearm,  and  to  be  accom- 
panied with  ostitis  and  osteo-myelitis  of  the  bones.  It  is  more 
likely  to  be  successful  in  cases  of  ankylosis  after  a  first  excision, 
but  every  surgeon  must  have  seen  how  persistent  in  some  cases  is 
the  tendency  to  ankylosis.  In  flail-like  union,  where  the  limb  re- 
mains quite  useless  in  spite  of  the  use  of  a  leather  support;§  where 

*  The  greater  breadth  and  deptli  of  the  trochlear  surface  on  the  back  than  on 
the  front  of  the  hnmerns  must  be  remembered. 

f  In  cases  of  bony  ankylosis,  it  is  best,  before  attempting  to  make  sections  of  the 
bones,  either  to  break  down  tlie  union  forcibly  (care  being  taken  not  to  fracture  the 
possibly  atrophied  bones  above  and  below),  or  to  divide  the  bony  ankylosis  with 
an  osteotome  or  saw. 

X  Mr.  Whitehead  {Brit.  Med.  Journ.,  1872,  vol.  ii.  p.  534)  records  the  case  of  an 
adult  in  which  2j  inches  of  the  shaft  of  the  humerus  had  to  be  removed  after  saw- 
ing off  the  condyles.     Nine  months  later  the  patient  had  full  use  of  the  elbow. 

§  See  the  case  mentioned  below. 


EXCISION    OF    ELBOW- JOINT.  75 

the  muscles  are  not  helplessly  wasted,  and  no  neuralgia  is  present, 
re-excision  should  be  tried  in  preference  to  amputation,  and  a  trial 
may  be  made  of  uniting  the  bones  witli  stout  silk  or  Avitli  wire. 

Where  pulpy  disease  persists,  as  indicated  by  continued  swell- 
ing, sinuses,  oedematous  granulations,  the  sinuses  should  be  per- 
severingly  laid  open  again  and  again,  scraped  out  with  sharp  spoons, 
carious  soft  bone  chipped  away  or  gouged.  The  heemorrhage  is 
often  free,  but  yields  to  pressure.  As  soon  as  the  parts  admit  of  it, 
firm  strapping  should  be  applied  for  a  few  days. 

As  long  as  no  disease  exists  elsewhere,  as  long  as  the  shafts  of 
the  bone  are  sound,  and  the  pulpy  mischief  has  not  burrowed  out 
into  the  muscles  beyond  a  ruptured  capsule,  a  hopeful  prognosis 
may  l^e  given. 

Excision  in  Cases  of  Gunshot  Wounds. — The  following 
points  are  brought  out  by  Dr.  Otis  as  the  results  of  this  operation 
in  the  great  Civil  War  of  America  {Med.  and  Sury.  Hist  of  the  TFar 
of  the  Behellion,  pt.  ii.  p.  845  et  seq.).  Compared  with  excision  of 
the  shoulder,  the  results  were  less  brilliant.  The  cases  are  divided 
into  the  following  groups :  I.  Primary  Excisions. — 250  cases,  with  a 
death-rate  of  21.3  per  cent.  27  of  the  250  were  ultimately  ampu- 
tated. II.  Intermediate  Excisions,  i.e.,  during  time  of  inflammation, 
three  to  four  weeks. — 197  cases,  with  a  death-rate  of  35.2  per  cent., 
nearly  14  per  cent,  greater  than  that  of  primary  excision.  19  were 
submitted  to  amputation  later  on;  62,  or  nearly  half  of  the  cases, 
were  reported  to  have  complete  ankylosis.*  III.  Secondary  Ex- 
cisions, thirty  days  or  more  after  the  injury. — 54  cases,  with  a  mor- 
tality of  9  per  cent. 

Period,  of  Election. — Dr.  Otis,  after  remarking  that  this  has  hitherto 
been  unsettled,  states :  "I  believe  that  the  evidence,  when  fully 
analyzed,  will  demonstrate  that  this  resection  conforms  to  the  gen- 
eral rule  in  shot  fractures  of  the  limbs,  that  primar}^  operations  are 
preferable  whenever  it  is  certain  that  recourse  must  eventually  be 
had  to  operative  interference." 

Amount  of  Bone  to  be  Removed. — While  complete  resectionf  gives 
more  favorable  results  both  as  to  life  and  the  utility  of  the  limb. 
Dr.  Otis  evidently  considers  it  as  yet  unsettled  whether,  in  cases 
where  the  joint  is  freely  opened,  but  only  the  humerus  or  the  bones 


*  Tlius,  if  patients  escape  the  risks  of  operations  on  inflamed  soft  parts,  bones, 
etc.  (p.  68),  the  ultimate  result  may  be  a  fixed  joint. 

t  In  some  of  the  above  cases  removal  of  detached  fragments  seems  all  that  was 
done.  This  incomplete  operation  does  not  appear  to  be  more  successful  in  military 
than  in  civil  surgery.  As  pointed  out  by  Prof.  Esmarcli,  free  division  of  the  cap- 
sule of  the  joint  deprives  the  wound  of  much  of  its  danger. 


76  OPERATIONS    OX    THE    UPPER    EXTREMITY. 

of  the  forearm  are  injured,  removal  of  the  injured  bones  alone  will 
not  be  better. 

Of  other  recent  wars,  the  results  of  the  Dano-Prussian  War  of 
1864  are  disputed.  The  Prussian  surgeons  have  claimed  good 
results  after  excision  of  the  elbow,  owing  to  (1)  the  part  taken  in 
the  care  of  the  wounded  by  such  eminent  men  as  Esmarch,  (2)  b}'- 
there  being  no  need  to  transport  the  wounded  very  far.  The  truth 
of  the  above  success  has  been  called  in  question,*  owing  to  the  fre- 
quency with  which  flail  joints  were  met  with  1.)}^  Danish  surgeons 
amongst  Danes  operated  on  by  Prussian  surgeons. 

With  regard  to  the  results  of  this  operation  in  the  Franco- 
German  War,  Dr.  Otis  (p.  904)  says  that  the  average  results  met 
with  by  the  Prussian  surgeons  are  not  discouraging,  but  the  results 
reported  by  the  surgeons  attached  to  the  French  army  of  that  day 
are  "simply  appalling." 

Unfavorable  Results  of  Elbow  Excision. 

1.  Persistence  of  pulpy  disease.  This  is  especially  likely  when, 
previous  to  the  operation,  the  capsule  has  been-  perforated  and 
pulpy  disease  has  burrowed  out  amongst  the  flexors  or  extensors. 

2.  Caries  and  chronic  osteo-myelitis.  These  are  not  unlikely  to 
supervene  when  the  reparative  power  is  poor  and  the  wound  be- 
comes septic. 

3.  Ankylosis.  This  is  not  uncommon  in  "children,  owing  to  the 
great  tendency  of  inflammatory  products  to  organize  quickly  in 
early  life.  Furthermore,  there  is  the  difficulty  of  getting  them  to 
use  the  joint  or  submit  to  passive  movement.  All  they  will  do  is 
to  move  their  arm  and  forearm  from  the  shoulder-joint  (p.  73). 

4.  A  flail-like  joint.f  A  limb  may  remain  weak  for  some  time, 
owing  to  the  muscles  not  taking  on  fresh  attachments.  Friction 
and  galvanism  should  be  used  perseveringly.  If  there  is  too  much 
separation  between  the  ends,  the  patient  should  wear  a  well- 
moulded  support;  the  use  of  the  hand  and  fingers  will  thus  be  re- 
tained, and,  if  the  patient  is  young,  gradual  and  great  improvement 
will  very  likely  take  place  in  the  elbow. 

If  the  wound  becomes  septic — 

5.  Cellulitis,  erysipelas,  etc. 

*  See  a  review  of  a  paper  by  Dr.  Hannover  {Brit.  Med.Jnurn.,  January  15,  1870, 
and  Med.-Chir.  Rev.,  1871),  and  a  reply  by  Dr.  Loeffler  {Bril.  Med.  Journ.,  May  '2S, 
1870). 

t  Mr.  C.  Forster  (Lancet,  1872,  vol.  i.  p.  3).  In  a  case  in  wliicli  tlie  right  limb 
was  a  perfect  flail,  with  the  help  of  a  leather  moulded  splint  all  the  movements  of 
the  fingers  were  good,  and  the  patient  could  do  needlework  and  write  well.  Such 
a  splint  is  capped  to  the  shoulder  and  moulded  to  the  limb  down  to  the  wrist,  leav- 
ing the  fingers  free,  and  strapped  round  the  chest. 


UNUNITED  FRACTURE  OF  OLECRANON.  77 

6.  Secondary  ha?morrhage.  This  occurred  in  11  out  of  250  cases. 
Otis,  loc.  cit,  p.  860. 

7.  A  useless  limb,  owing  to  utterly  wasted  muscles  from  long  dis- 
ease and  disuse. 

8.  Adherent  scar. 

EXCISION  OF  SUPERIOR  RADIO-ULNAR  JOINT. 

Indications. — This  operation  may  be,  very  occasionally,  called 
for  and  justifiably  made  use  of,  with  antiseptic  precautions,  in  old 
cases  of  dislocation  of  the  head  of  the  radius,  where  reduction  has  not 
been  effected  owing  to  the  amount  of  swelling,  etc.,  and  where  the 
movements  of  the  forearm  are  much  hampered,  especially  in  a  young 
and  healthy  adult. 

Operation. — An  incision  about  2  inches  long  is  made  over  the 
projecting  head  of  the  bone  behind  or  through  the  posterior  part  of 
the  supinator  longus.*  The  soft  parts  being  separated  with  a  blunt 
dissector  and  held  aside  with  retractors,  the  neck  of  the  radius  is  care- 
fully divided  with  a  fine  saw  or  cutting  l)one-forceps.  Sufficient  bpne 
must  be  removed  here  or  from  the  external  condyle  to  leave  a  gap 
and  avoid  risk  of  fresh  ankylosis.  Tiie  musculo-spiral  nerve  lies  to 
the  inner  side,  and  great  care  must  be  taken  not  to  interfere  with  this 
or  the  biceps  tendon.  The  forearm  should  be  put  through  its  move- 
ments freely,  but  carefully,  while  the  patient  is  under  the  anaesthetic, 
so  as  to  break  down  adhesions.  Sufficient  drainage  must  be  provided, 
and  every  care  taken,  by  not  interfering  with  the  soft  parts  more  than 
is  absolutely  needful,  and  by  keeping  the  wound  aseptic,  to  secure 
primary  union,  and  thus  avoid  the  risk  of  stiffness  again  occurring. 
After  a  few  days  a  sling  may  be  substituted  for  a  splint,  and  passive 
movements  made  use  of  daily,  with  the  aid  of  an  anaesthetic  if  needful. 

Mr.  Wainewright  {Clin.  Snc.  Trans.,  vol.  xix.  p.  332)  records  a  some- 
what analogous  case,  in  which,  in  an  adult,  he  removed  the  head  of 
the  radius,  which  was  vertically  fractured,  and  the  coronoid  process, 
which  had  been  imperfectly  united  with  fibrous  tissue.  The  accident 
had  taken  place  three  months  before.  The  movements  of  the  liml) 
were  distinct!}^  improved  by  the  operation. 

UNUNITED  FRACTURE  OF  OLECRANON. 

Wiring  the  fragments  of  this  bone  is  not  often  required.  For  fuller 
details  the  reader  is  referred  to  the  remarks  on  treatment  of  ununited 

patella  by  wiring. 

n^ — 

*  The  operation  will  be  somewhat  easier  in  tiie  backward  dislocation,  when  the 
radius  rests  on  tiie  back  and  outer  surface  of  the  external  condyle,  than  in  the  forward 
displacement,  when  the  head  rests  on  the  front  of  tlie  liumerus  in  tlie  hollow  above  tlie 
condvle. 


78  OPERATIONS    OS    THE    UPPER    EXTREMITY. 

Indications. — (1)  Where,  in  spite  of  careful  treatment  previously 
employed,  the  limb  is  weak  and  its  usefulness  seriously  interfered 
with,  especially  where  the  occupation  of  the  patient  requires  vigorous 
extension  of  the  elbow. ^  (2)  Where  such  treatment  has'  not  been 
used,  but  the  time  for  it  has  gone  by.  In  either  case  the  patient 
should  be  in  a  good  condition  of  health,  and  the  younger  the  better. 
The  object  of  the  operation  and  its  possible  risks  should  be  fully  ex- 
23lained  to  hnii.  It  is  taken  for  granted  that  a  surgeon  understanding 
this  operation  has  good  reason  for  feeling  confident  in  his  knowledge 
of  antiseptic  surgery. 

OpGration. — The  parts  being  rendered  evascular  by  properly  ap- 
plied Esmarch's  bandages,  and  the  region  of  the  elbow-joint  duly 
cleansed,!  a  longitudinal  incision  is  made  for  2^  or  3  inches  over  the 
back  of  the  joint,  opening  into  this  and  exposing  the  fragments.  Any 
adhesions — e.g.^  between  these  and  the  condyles — are  then  removed 
or  broken  down.  Retractors  being  placed  in  the  wound,  the  peri- 
osteum is  separated  from  the  contiguous  edges  of  the  fragments,  and 
a  thin  layer  of  bone  removed  from  each  fragment,  either  with  a  chisel 
or  a  narrow,  sharp  saw.  A  hole  is  then  drilled  obliquely  through 
each  fragment  with  a  brad-awl  or  drill,  and  stout;|:  silver  wire  passed§ 
and  twisted  up.  Two  half-twists  or  one  complete  twist  should  be 
sufficient.  If  the  surgeon  decides  to  leave  the  wire  in,  he  now  cuts 
the  ends  short  and  hammers  them  down  ujion  the  olecranon  with  a 
small  hammer.  If  he  is  going  to  remove  them  later  on,  he  leaves  the 
ends,  not  cut  too  short,  projecting  through  the  wound,  which  is  next 
closed  with  silk  or  wire  sutures. 

Two  questions  arise  here.  One,  Should  the  wire  be  left  or  no  ?  I 
have. alluded  to  this  question  more  fully  later  on,  in  the  treatment  of 
fractured  patella  by  wiring.  While  one  objection  there  given  is  want- 
ing here — viz.,  the  inability  to  bear  pressure  on  the  wire,  as  in  kneel- 
ing— two  others  remain,  viz.,  the  fact  that,  in  some  patients,  attention 
will  be  constantly  attracted  to  the  presence  of  the  wire,  and  that,  after 
a  time,  ulceration  may  set  in  around  the  wire  and  cause  trouble. 

*  The  surgeon  will  examine  how  far  this  power  is  lost,  to  what  extent  wasting  of 
the  triceps  has  occurred,  and  what  evidence  of  union  there  is  in  the  sutures  between 
the  fragments. 

f  First  by  the  use  of  soap  and  carbolic  oil,  and  then  with  carbolic  acid  lotion  (1  in 
40),  a  piece  of  lint  soaked  in  this  being  worn  over  the  joint  for  an  hour  or  two  before 
the  operation. 

X  Sir  J.  Lister  {Lancet,  1883,  vol.  ii.  p.  761)  gives  wire  about  ^V  i"ch  as  amply 
sufficient  for  the  olecranon,  while  for  the  shaft  of  the  femur,  in  an  adult  male,  a  piece 
of  wire  about  y^  inch  in  thickness  is  requisite  in  order  to  resist  with  certainty  the 
enormous  force  of  the  great  muscles  of  the  thigh. 

I  For  difficulties  in  this,  and  how  to  meet  them,  see  "  Wiring  of  the  Patella." 


VENESECTION.  79 

Thus  I  believe  it  to  be  better  in  most  cases  to  leave  the  wire  ends 
fairly  long,  not  short  and  hammered  down,  and  to  remove  them  in 
about  six  or  eight  weeks'  time.  The  other  course,  no  doubt,  enables 
the  surgeon  to  allow  his  patient  to  return  to  work  after  a  mUch  shorter 
interval,  viz.,  three  or  four  weeks,  but,  as  I  think,  at  an  undoubted 
risk. 

The  other  question  is  about  the  drainage.  If  the  parts  have  not 
been  much  interfered  with,  if  no  separation  of  adhesions  has  been 
necessary,  j^robably  no  drainage  will  be  needful  if  dry -gauze  dressings 
are  applied,  and  firm  and  even  support  given  with  bandaging.  If 
drainage  is  considered  advisable,  a  catgut  drain  will  probably  be  suf- 
ficient. 

In  about  six  or  eight  weeks'  time  the  wire  may  be  removed,  careful 
note  having  been  made,  at  the  time  of  the  operation,  of  the  number 
of  half-twists.  Occasionall}^  here,'^  as  in  the  case  of  the  patella, 
removal  of  the  wire  is  a  matter  of  some  difficulty, 

VENESECTION. 
Indications. 

1.  Some  cases  of  traumatic  pneumonia  and  injury  to  ribs,  as  where 
a  stout  young  farmer  breaks  several  ribs  when  riding,  and  acute  pneu- 
monia sets  in  and  extends  rapidly.  Here  the  cyanosis,  orthopnoea, 
the  distressing  pain,  ma}^  all  be  relieved  by  a  bleeding  of  8  to  10 
ounces,  which  very  likely  will  have  to  be  repeated. 

In  other  cases  of  acute  pneumonia  which  are  not  traumatic,  bleed- 
ing may  be  resorted  to  with  great  advantage  when  the  patient  is  young 
and  plethoric,  the  breathing  much  oppressed,  and  the  heart's  action 
becoming  embarrassed. 

2.  In  some  cases  of  chronic  bronchitis.  Dr.  Haref  draws  this 
graphic  picture  of  such  a  case.  A  middle-aged  man  with  chronic 
bronchitis  and  some  congestion  of  the  lungs  has  exj^osed  himself  to 
chill.  "  He  is  sitting  in  a  chair  (to  lie  down  is  impossible  for  him), 
his  face  is  blue  and  sunken,  his  lips  purple,  the  eyes  suff"used  and 
staring,  ....  his  chest  heaving,  and  each  short  gasping  inspiration 
followed  by  a  long  wheezing  and  moaning  expiration  ;  his  lungs  are 
full  of  moist,  sonorous,  and  mucous  rhonchi,  scarcely  a  trace  of 
vesicular  murmur  is  to  be  heard,  and  he  is  pulseless.     He  looks  to 

*  In  a  case  of  Sir  J.  Lister's  (loc.  supra  ciL),  the  wire  was  not  completely  removed 
from  tiie  olecranon,  for,  the  loop  having  given  way  near  the  twist,  the  twisted  part  was 
alone  taken  away,  and  the  loop  left  behind,  but  without  causing  any  inconvenience 
when  the  patient  was  last  heard  of. 

f  Brit.  Med  Journ.,  1883,  vol.  i.  p.  156:  "Good  Remedies  Out  of  Fashion."  Other 
forms  of  blood-abstraction,  such  as  leeches  and  cupi)ing,  are  spoken  of  here.  The 
whole  address  is  well  worthy  of  careful  study. 


80  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

you  beseechingly,  and  gasps  out,  in  scarcely  articulate  words,  that  he 
is  dying.  This  is  but  true.  Now  the  treatment  for  such  a  condition 
at  the  present  day  is  to  '  pour  in  stimulants  '  (though  the  patient  can 
scarcely  swallow).  Brandy  and  water  are  given,  and  ammonia,  and 
perhaps  ether;  then,  if  the  patient  lives  long  enough,  mustard  poul- 
tices are  applied  to  the  chest  and  the  calves  and  feet,  and  the  patient 

is  fanned,  and  the  patient  dies Appearances  have  been  saved, 

but  not  the  patient's  life.  The  fact  is  that  here  the  danger  lay  in  the 
right  side  of  the  heart  being  gorged  with  blood,  so  that  it  was  impos- 
sible for  its  stretched  and  distended  Avails  to  contract  and  to  propel 

forwards  the  thick  and  blackened  l;)lood Open  one  of  these 

veins,  which  are,  with  every  systole  of  the  heart,  tending  to  carry 
more  and  more  blood  to  this  already  distended  right  ventricle,  and  all 
may  yet  be  well  with  your  patient." 

3.  Where  a  tendency  to  apoplectic  seizures  exists,*  Dr.  Hare  {loc. 
supra  cit.)  thus  speaks  of  this  class  of  case.  Nature  speaks  "  in  unmis- 
takable language  when  by  a  copious  epistaxis  she  efficiently  relieves, 
the  congested  turgid  face,t  the  beating  temples,  the  dull  heavy  head- 
ache, the  sleepiness,  the  confusion  of  thought,  and  other  symptoms, 
which  in  a  plethoric  individual  betoken,  if  they  are  not  relieved, 
serious  danger,  if  not  an  apoplectic  attack." 

4.  In  aneurisms,  especially  thoracic.  As  part  of  the  treatment  of 
Valsalva  in  a  modified  form.  Formerly  the  bleedings  in  aneurism 
were  copious,  even  to  syncope.  Nowadays  they  are  made  use  of  in  a 
different  way.  They  are  small  in  amount,  and  are  only  repeated  so 
far  as  to  reduce  excessive  action  of  the  heart,  or  to  relieve  certain 
symptoms  (as  they  undoubtedly  do) — viz.,  dyspnoea  and  pain. 

Operation.— The  patient  being  usually  in  a  sitting  position,  and 
a  bandage  tied  round  the  middle  of  the  arm  with  sufficient  tightness 
to  retard  the  venous  circulation  without  arresting  that  of  the  arteries, | 
the  surgeon  selects  a  vein  for  his  purpose,  either  the  median  cephalic 
or  the  median  basilic,  whichever  is  most  prominent.§  Steadying  this 
vein  by  placing  his  left  thumb  upon  it  just  below  the  point  of  intended 

*  This  does  not  niean  these  cases  wJiere  a  rupture  of  a  cerebral  vessel  has  occurred, 
where  bleeding  would  interfere  witii  tliat  process  of  repair  on  which  the  patient's  life 
depends. 

t  Dr.  Copeman  (Brit.  Med.  Journ.,  1879,  vol.  ii.  p.  932)  points  out  that  in  these 
cases,  in  addition  to  plethora  and  a  full  liabit,  evident  distension  of  the  superficial 
veins  of  the  head  and  neck  is  a  valuable  indication  that  bleeding  is  proper. 

X  The  surgeon  makes  use  of  the  pulsation  in  tlie  arteries  to  tell  the  relation  of  the 
brachial,  or  one  of  its  branches  given  ofT  abnormally  high  up  and  running  superficially, 
to  the  veins  at  the  bend  of  the  elbow. 

§  If  the  patient  is  nervous,  or  if  the  veins  are  small,  he  should  be  told  to  liold  a 
walking-stick  or  book.  This  steadies  his  arm,  distracts  his  thoughls,  and  by  producing 
muscular  contraction  supports  and  fills  the  veins. 


VENESECTIOX.  81 

puncture,  and  with  his  left  hand  steady  also,  he  opens  the  vein  with 
the  point  of  a  lancet  or  small,  sharp  scalpel  (whichever  is  used  should 
be  scrupulousl^y  clean),  making  with  a  gentle  sweep  of  his  wrist  a 
small  incision,  and  not  a  mere  puncture,  into  the  vein.  The  anterior 
wall  of  this  being  divided,  and  the  blood  flowing,  the  point,  without 
penetrating  any  deeper,  is  thrust  onwards,  first  increasing  the  slit  in 
the  vein,  and  then  being  brought  out  vertically,  care  being  taken  to 
make  the  skin  wound  larger  than  that  in  the  vein.-  The  lancet  or 
scalpel  being  laid  aside  and  the  bleeding-glass  held  near,  the  thumb 
is  now  raised  and  the  stream  directed  into  the  glass.*  While  the 
blood  is  escaping,  the  limb  should  be  kept  in  the  same  position,  lest, 
by  the  skin  slipping  over  the  wound  in  the  vein,  the  blood  should 
be  prevented  from  escaping  freely  and  make  its  way  into  the  cellular 
tissue. 

The  required  amount  of  blood  having  been  removed,  the  thumb  is 
placed  on  the  puncture  while  the  bandage  is  taken  from  the  arm.  A 
small  pad  of  lint  dusted  with  iodoform  or  of  dry  aseptic  gauze  is  then 
placed  on  the  puncture,  and  secured  with  tape  or  bandage  applied  in 
the  figure  of  8.  This  pad  may  be  removed  in  twenty-four  or  forty- 
eight  hours,  and  for  a  day  or  two  the  patient  should  carry  his  arm  in 
a  sling. 

Difficulties  during,  and  Complications  after,  Venesection. 

1.  Difficulty  in  finding  a  vein.  This  may  be  due  to  their  small 
size,  the  feebleness  of  the  circulation,  or  the  abundance  of  fat.  If  a 
vein  cannot  be  made  sufficiently  distinct  by  hanging  down  the  limb, 
putting  it  in  warm  water,  flexing  and  extending  the  wrist  and  fingers, 
and  chafing  the  limb,  a  vein  should  be  opened  on  the  back  of  the 
hand,  or  blood  withdrawn  from  the  external  jugular  or  internal 
saphena  at  the  ankle. 

2.  In  other  cases,  where  the  patient  is  much  emaciated,  owing  to 
the  absence  of  steadying  fat  the  mobility  of  a  vein  may  enable  it  to 
avoid  puncture  unless  a  very  sharp  instrument  is  used  and  the  vein 
well  steadied. 

3.  When  the  vein  has  been  opened,  sufficient  blood  may  not  escape 
owing  to — 

(a)  The  opening  being  a  mere  puncture. 

{b)  The  skin-oj)ening  being  insufficient  in  size,  or  not  parallel  in 
position  to  that  in  the  vein.  These  impediments  are  re- 
moved by  a  freer  use  of  the  knife,  carefully  made,  or  by 
bringing  the  wound  in  the  vein  parallel  with  that  in  the 
skin. 

*  Not  a  drop  of  blood  should  be  allowed  to  go  on  to  llie  bed  or  patient's  linen. 

6 


82  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

(c)  A  pellet  of  fat  may  block  the  opening  in  the  vein.     This 

should  be  snipped  away. 
{d)  The  patient  may  faint, 
(e)  A  thrombus  may  form.     This  will  disappear  Avhen  the  venous 

current  becomes  more  active. 
(/)  The  bandage  may  be  tied  too  tightly  round  the  arm. 

4.  Wound  of  the  brachial  or  some  other  artery — e.  g.,  an  abnormal 
ulnar.  This  can  always  be  avoided  by  a  careful  use  of  the  lancet  or 
scalpel,  and  by  noting  beforehand  the  existence  of  any  pulsation.  The 
force  of  the  jet  and  the  mixture  of  bright  with  dark  blood  will  tell  of 
this  accident.  Pressure  should  be  carefully  applied  and  maintained, 
and  blood  taken  from  the  opposite  arm  if  required. 

5.  Escape  of  blood  into  the  cellular  tissue.  This  will  lead  to  ecchy- 
mosis,  and  perhaps  formation  of  a  thrombus,  which  may  be  absorbed, 
but  which  also  may  suppurate. 

6.  Phlebitis,  or  inflammation  of  the  lymphatics.  These  may  be 
due  to  use  of  dirty  instruments,  aided  by  the  low  condition  of  the 
patient.  The}^  should  be  most  carefully  guarded  against,  as  likely  to 
lead  to  the  following  two  most  grave  results. 

7.  Erysipelas  and  cellulitis. 

8.  Intense  pain  in  the  limb,  with  gradual  flexion  of  the  elbow-joint. 
This  is  due  to  puncture  of  the  external  or  internal  cutaneous  nerves, 
Avhich  are  connected  through  the  brachial  plexus  with  the  motor 
nerves  to  the  brachialis  anticus  and  biceps,  which  flex  the  elbow- 
joint.*  The  injured  nerves  should  be  divided,  subcutaneously  if  pos- 
sible. 

TRANSFUSION. 

This  operation  is  rarely  performed — (1)  from  the  fact  that  it  is 
apparently  very  fatal,  though  the  bad  results  are,  as  in  tracheotoni}'- 
for  croup  or  in  herniotomy  in  cases  of  strangulation,  not  due  so  much 
to  the  operation  itself,  as  to  the  condition  which  calls  for  it.  (2)  From 
the  difficulties  attending  the  operation.  These,  of  late  years,  have 
been  much  diminished,  but,  while  we  have  simpler  apparatus  at  hand, 
it  is  probably  still  correct  that  there  is  none  which  has  been  used  suf- 
ficiently often  to  be  called  perfect.  Yet  it  is  an  operation  with  which 
every  practitioner  should  be  acquainted,  owing  to  the  critical  nature 
of  the  cases  in  which  he  is  called  upon  to  perform  it,  and  the  sudden- 
ness with  which  the  call  is  liable  to  come. 

There  are  two  methods:  A.  Direct,  in  which  blood  is  conveyed 
directly  from  one  person  into  another  ;  and  B.  Indirect,  in  which 
blood  is  separated  from  its  fibrin,  or  some  other  fluid  is  throAvn  in. 

A.  Direct. — These  will  be  described  first  and  most  fully,  as  it  is 

*  Hilton,  Rest  and  Pain,  p.  190. 


TRANSFUSION. 


83 


probably  far  preferable  to  inject  blood  without  exposure  to  air  and 
without  mani23ulation,  and  as,  save  in  a  very  few  cases,  one  of  the 
direct  methods  with  the  simple  apparatus  of  the  present  day  will  be 
usually  available. 
Chief  Methods. 

1.  Dr.  Galabin's. 

2.  Dr.  Aveling's,  and  Mr.  Cripps's  modification  of  it. 

3.  Roussel's. 

1.  Dr.  Galabin's  (Fig.  25). — This  is  by  far  the  simplest  of  the  direct 
transfusion  methods  ;  it  is,  furthermore,  cheap,  and  easily  and  quickly 
cleaned — points  of  much  importance  in  an  instrument  which  is  wanted 
at  a  few  minutes'  notice,  and  then  may  be  laid  by  for  a  long  time. 
Finally,  it  can  be  used  both  for  direct  and  indirect  transfusion.  Its 
disadvantage  is  that  when  used  for  direct  transfusion  the  quantity  of 
blood  cannot  be  easily  and  exactly  measured. 

It  consists  (Fig.  25)  of  a  piece  of  elastic  tubing,  about  a  foot  long, 
which  can  be  easily  replaced  from  time  to  time  at  very  slight  cost, 

Fig.  25. 


Galabin'.s  transfusion  apparatus. 

A  and  B.  Terminals  of  the  cannula.  The  intervening  india-rubber  tube  should  uot  be  more 
than  r>  or  6  inches  long,  to  diminish  the  risks  of  clotting. 

c.  Receiving  cannula,  with  a  conical  end  to  fill  the  opening  into  the  vein. 

D.  Delivering  cannula,  with  a  pointed  end  so  as  to  slip  readily  into  the  probably  empty  vein 
of  the  patient. 

even  b}'  ordinar}^  drainage-tube,  there  thus  being  no  risk  of  finding 
the  apparatus  cracked  and  useless  at  the  moment  of  need.  At  either 
end  are  terminals  and  cannulse,  after  the  shape  of  Dr.  Aveling's  pat- 
tern, with  as  little  projection  of  rim  as  possible  when  united  to  the 


84  OPERATIONS    ON   THE    UPPER    EXTREMITY. 

tubing  or  cannulte.  For  the  same  purpose— i.e.,  to  avoid  starting- 
points  for  clotting — Dr.  Galabin  does  away  with  any  taps  at  the  junc- 
tion of  the  terminals  and  cannulfe,  using  spring-clips  instead  (Fig. 
25).  The  following  is  the  way  of  using  the  apparatus,  taken  from  Dr. 
Galabin 's  paper*  (p.  268):  "Place  the  transfusion  tube,  including 
terminals  and  cannulse,  in  a  hot  solution  of  common  salt  (5j-0j). 
When  the  tube  is  full,  and  all  air  removed  from  it,  place  a  spring-clip 
on  it  at  each  end,  close  to  the  terminals.  Tie  tapes  round  the  arm  of 
the  receiver,  first  above  and  then  below  the  vein  which  is  to  be  opened. 
Prepare  the  vein  by  exposing  a  portion  of  it,  and  passing  a  probe 
underneath  it.  Then  tie  tapes  round  the  arm  of  the  donor,  first  above 
and  then  below  the  point  where  tlie  vein  is  to  be  opened.  Expose 
the  vein  and  pass  a  probe  beneath  it.  Now  let  the  donor  sit  by  the 
bedside  and  place  his  arm  close  to  that  of  the  patient.  Take  the 
delivery  cannula,  d,  out  of  the  saline  solution,  open  the  receiver's 
vein  by  a  snip  with  sharp-pointed  scissors,t  and  see  that  the  cannula 
slips  readily  into  it.  Removing  the  cannula,  pass  a  small  director 
into  the  vein,  that  the  opening  may  not  be  lost,  and  remove  the  tape 
above  the  opening.  Now  take  the  transfusion  tube,  with  both  can- 
nula affixed,  open  the  donor's  vein  by  a  snip  with  scissors,  and  slip 
the  receiving  cannula,  c,  into  it,  passing  it  gently  on  so  far  that  by  its 
conical  shape  it  fills  the  vein  and  does  not  allow  blood  to  escape  by 
the  side.  Let  an  assistant  hold  the  cannula  in  place,  remove  the 
lower  tape  from  the  donor's  arm,  and  remove  the  spring  clips,  keeping 
the  delivery  cannula  slightly  raised  above  the  donor's  vein.  As  soon 
as  blood  begins  to  flow  from  the  delivery  cannula,  slip  the  cannula 
into  the  receiver's  vein  and  hold  it  there,  having  passed  it  in  far 
enough  to  prevent  escape  of  blood  by  the  side,  as  in  the  case  of  the 
receiving  cannula.  The  flow  will  be  aided  if  the  receiver's  arm  is 
raised  on  a  pillow  slightly  above  the  level  of  the  shoulder." 

As  by  this  method  the  quantity  of  blood  transfused  cannot  be 
measured,  the  surgeon  must  judge  when  to  leave  oft'  by  the  time  of 
the  flow,  which  should  not  be  less  than  five  minutes,  and  partly  by 
the  effect  on  the  pulses  of  the  donor  and  receiver.  When  the  cannulse 
are  withdrawn  the  remaining  tapes  are  removed,  and  the  veins  closed 
by  a  pad  and  bandage. 

2.  Dr.  Aveling's,  with  Mr.  Cripps's  Modification  (Fig.  26). — 
While  this  method  has  the  advantage  of  being  amongst  the  simpler 
and  inexpensive  forms  of  direct  transfusion,  it  is,  in  my  opinion,  in- 
ferior to  that  above  described,  for  reasons  given  below.     It  has,  how- 

*  G'mj/'s  Hospital  Eeports,  vol.  xlii.  p.  255. 

t  All  the  instruments  used  should  be  scrupiilonsly  clean,  and  taken,  previously  to 
use,  o\it  of  a  solution  of  carbolic  acid  or  mercury  perchloride  solution. 


TRANSFUSION. 


85 


ever,  one  advantage  over  it,  of  measuring  the  amount  of  blood  sent — 
viz.,  2  drachms  at  each  squeeze  of  the  central  bulb. 

Mr.  Cripps  has  removed  one  source  of  clotting  by  replacing  the  taps 
shown  in  Fig.  26  by  clips,  as  in  Dr.  Galabin's  apparatus.  But  though 
made  of  the  best  rubber,  and  in  one  piece,  it  is  more  likely,  when  put 
aside  for  long  intervals,  to  be  found  cracked  and  rough,  and  thus  less 
easily  replaced  than  the  simple  bit  of  tubing  of  which  Dr.  Galabin's 
instrument  consists. 

The  veins  being  exposed,  as  already  directed  (p.  84),  the  apparatus 
is  filled  with  a  warm  solution  of  sodium  chloride,  and  a  clip  placed  at 
either  end.  The  arms  of  receiver  and  donor  being  in  the  position 
given  below,  the  vein  of  the  receiver  is  opened,  and  pressure  being 
made  just  below  the  opening  in  the  vein,  so  as  to  prevent  blood  ob- 

FiG.  26. 


A  and  B  are  the  hands  of  assistants  holding  the  afferent  and  efferent  tubes  and  the  lips  of  each 
venesection  wound  together.  The  cannulae  being  inserted  into  the  veins,  the  syringe  and  tubing, 
filled  with  warm  saline  solution,  and  kept  so  by  the  taps  or  clips,  is  fitted  into  the  cannulfe.  Then 
the  taps  are  turned  or  the  clips  removed,  and  the  tubing  compressed  by  d,  and  the  bulb  squeezed 
by  c.  The  tube  is  then  squeezed  by  shifting  d  to  d'.  The  bulb  then  expanding  draws  in  blood, 
when  the  manipulation  just  described  is  repeated.  The  bevelled  end  of  the  afferent  tube  is  so 
made  that  it  may  slip  easily  into  the  collapsed  vein  of  the  patient.    (Aveling.*) 

scuring  the  opening,  the  cannula  is  inserted.  The  other  cannula  is 
then  inserted  into  a  vein  of  the  giver,  and  both  held  steadily  by  an 
assistant.     Transfusion  is  then  performed  as  follows  :t 

"  The  clips  having  been  removed  from  the  tube  at  either  end,  the 
operator  makes  the  necessary  valve  to  prevent  regurgitation  by  com- 
pressing, with  the  finger  and  thumb  of  one  hand,  the  tube  l)etween 
the  central  ball  and  the  giver.    He  then  slowly  squeezes  the  ball,  with 


*  Obst.  Trans.,  vol.  vi.  May  4,  1874. 
f  Cripps,  Diet,  of  Surg.,  vol.  ii.  p.  660. 


86  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

the  effect  of  driving  the  water  it  contains  gently  into  the  vein  of  the 
recipient ;  then,  having  compressed  the  tube  between  the  ball  {jnd  the 
recipient,  he  removes  the  finger  and  thumb  from  off  the  tube  on  the 
opposite  side,  allowing  the  ball  to  expand  with  the  blood  coming  into 
it  from  the  arm  of  the  giver.  When  the  l)all  is  full,  the  manipulation 
just  described  is  repeated,  and  the  blood  passes  into  the  vein  of  the 
receiver.  In  this  manner,  each  time  the  ball  is  compressed,  2  drachms 
of  blood  are  injected  into  the  veins  of  the  patient.  Should  the  syringe 
appear  to  become  blocked,*  or  work  unsatisfactorily,  it  can  be  detached 
and  washed  out  without  removing  the  cannula^  from  the  veins." 

3.  M.  Roussel's. — This  method  appears  to  me  to  have  the  following 
grave  objections:  (1)  Its  cost,t  which  is  very  high  for  an  instrument 
so  rarely  used.  (2)  Its  complicated  nature.  (3)  The  fact  that  its 
safety  depends  on  its  being  used  rapidly.  As  Dr.  Galabin  remarks, 
"  A  general  practitioner,  having  occasion  to  operate  but  once  in  a  life- 
time, might  occupy  more  time,  and  the  risk  to  the  patient  is  thus 
immediately  increased. ";{:  (4)  Although  the  first  few  ounces  of  blood 
pass  quite  successfully,  yet,  after  a  while,  clots  usually  form  in  the 
tube.§ 

B.  Indirect  Transfusion. — Points  which  have  here  to  be  con- 
sidered are|| — (1)  What  is  the  best  fluid  to  use.  (2)  What  is  the  best 
apparatus  and  method. 

Dr.  Galabin's  very  simple  apparatus  has  the  great  advantage  of 
being  available  for  indirect^  as  well  as  for  direct  transfusion. 

The  terminal  d,  and  delivery  cannula  b,  are  fitted  to  an  elastic  tube, 
about  3  feet  long,  and  not  less  than  y\  inch  in  calibre.  The  other  end 
is  attached  to  a  glass  funnel.  The  mode  of  procedure  will  then  be  as 
follows:  First  expose  the  receiver's  vein  and  place  a  probe  under  it; 
then  draw,  defibrinate,  and  filter  the  blood  through  muslin,  place  it 

*  A  case  in  which  this  occurred  will  be  found  related  by  Dr.  Hoggan,  Brit.  Med. 
Journ.,  1877,  vol.  ii.  p.  726. 

t  Five  guineas — Dr.  Galabin's  costing  18s.,  and  Dr.  Aveling's  £1  12s. 

X  Mr.  Ciipiis  {loc.  supra  cit.)  further  condemns  it  as  most  unsurgical,  and  as  "  mei'ely 
an  attempt  to  substitute  the  haphazard,  blind  puncture  of  a  machine  for  the  human 
fingers  and  eyesight,  which  are  alone  to  be  relied  on  in  performing  so  delicate  an 
operation  as  transfusion,  with  ease,  safety,  and  precision." 

§  It  is,  however,  only  fair  to  the  inventor  to  state  that  in  the  Yearbook  of  Treatment 
for  1886,  p.  90,  M.  Roussel  is  stated  to  have  performed  transfusion  by  his  method  suc- 
cessfully eighteen  times  in  thirty-nine  surgical  cases;  and  in  medical  cases  twenty- 
eight  times,  with  ten  recoveries.  No  information  is,  however,  given  in  the  book  just 
quoted  as  to  the  severity  of  the  cases  or  the  condition  of  the  patients. 

II  With  regard  to  the  fluid,  blood,  if  available  and  taken  from  a  healthy  patient,  is 
undoubtedly  the  best;  and  it  is  quite  clear  that  venous  blood  answers  every  ]>urpose. 

Tf  As  in  cases  where  the  only  donor  available  is  nervous  and  excited,  and  cannot  be 
relied  upon  to  go  throgh  direct  transfusion  steaiily. 


TRANSFUSION.  87 

in  a  small  jug,  which  is  kept  warm  in  a  basin  of  warm  water,  place  a 
spring  clip  at  the  end  of  the  transfusion  tube  close  to  the  terminal, 
hold  the  tube  vertical,  with  the  funnel  uppermost,  and  fill  the  funnel 
with  hot  solution  of  common  salt  (5j-Q))j  previously  prepared,  open 
the  spring  clip,  and  let  the  solution  run  out  till  the  funnel  is  just 
empty  and  the  tube  alone  full,  then  close  the  clip  again.  Now  pour 
the  blood  into  the  funnel,  open  the  clip  till  the  blood  begins  to  escape 
from  the  cannula,  and  then  close  it  again ;  open  the  receiver's  vein, 
and  slij)  the  cannula  into  it,  keeping  the  arm  somewhat  elevated  on 
a  pillow  above  the  level  of  the  shoulder.  When  the  clip  is  taken  off 
and  the  funnel  raised,  the  blood  will  generally  flow  in  by  the  force  of 
gravity.  The  funnel  must,  of  course,  be  kept  replenished  as  the  level 
of  the  blood  in  it  falls.  If  necessary,  the  flow  may  be  accelerated  by 
running  the  oiled  finger  and  thumb  down  the  tube.  But  if  the  flow 
seems  to  be  arrested,  or  nearl}^  arrested,  it  is  better  first  to  withdraw 
the  cannula  for  a  moment  from  the  vein,  and  make  sure  that  the  flow 
is  not  stopped  by  a  clot  in  the  cannula  or  tube. 

Dr.  Galabin  considers  this  simple  arrangement  of  funnel  and  tube 
equal  to,  and  even  superior  to,  any  more  complicated  india-rubber 
apparatus,  which  is  apt  to  be  found  unfit  for  use  when  wanted  unex- 
pectedly. 

If  the  surgeon  prefer,  he  can  make  use  of  much  the  same  apparatus, 
and  a  cannula  of  glass,  or  any  nozzle  of  appropriate  size,  always  re- 
membering that  the  end  must  be  fine  to  enter  the  vein,  usually  col- 
lapsed, of  the  patient,  and  that  any  taps,  changes  of  calibre,  etc.,  in 
the  cannula  or  nozzle  are  all  sources  of  coagulation,  and  thus  perhaps 
of  fatal  embolism. 

The  same  precautions  as  to  defibrination,  filtering,  keeping  up  the 
temperature  of  the  blood,  filling  the  tubing  with  warm  saline  solu- 
tion— in  fact,  taking  every  possible  step  to  prevent  coagulation  and 
the  transmission  of  emboli — must  be  most  carefully  followed. 

Other  fluids  which  have  been  recommended  as  well  as  blood  must 
be  here  briefly  considered. 

Milk*  has  been  used  by  some — e.g.,  Dr.  Thomas,  of  New  York — 
being  thought  to  be  safer  and  more  nutritious  than  saline  fluids.  Pos- 
sibly this  last  advantage  is  somewhat  theoretical,  being  based  on  the 
supposed   resemblance  to   chyle.     If  milk  be  injected,  it  should  be 

*  Prof.  Schafer  (Trans.  Obst.  Soc,  vol.  xxi.),  from  experiments  on  dogs,  found  that 
tlie  injection  of  milk,  after  they  had  been  reduced  by  bleeding  to  almost  a  lifeless  con- 
dition, caused  a  temporary  rise  in  the  blood  pressure,  but  no  permanent  benefit. 
After  death,  the  blood  corpuscles  were  found  to  be  disintegrated,  and  the  blood  swarm- 
ing with  bacteria.  He  was  strongly  of  opinion  that  no  fluid  lacking  hajmoglobin 
could  be  of  anv  benefit  in  cases  of  acute  ansemia. 


88  OPERATIONS  ON  THE  UPPER  EXTREMITY, 

first  most  carefully  filtered  to  prevent  any  capillary  embolism  in  the 
lungs. 

Saline  solutions  have  also  been  used,  being  always  available  in  the 
absence  of  a  fitting  blood  donor,  and  in  the  hope  that  thus  sufficient 
fluid  would  be  supplied  to  stimulate  the  failing  action  of  the  heart, 
and  to  give  it  something  to  contract  upon  until  the  processes  of 
assimilation,  which  are  in  these  cases  suspended,  can  once  again 
supply  natural  fluid  to  the  heart  and  vessels.  The  transfusion  of 
saline  solutions  received  at  one  time  some  impetus  from  a  certain 
amount  of  success  which  attended  their  use  in  cholera.  Thus  Mr. 
Little*  reports  four  recoveries  out  of  fifteen  cases  so  treated  at  the 
London  Hospital.  The  fluid  used  consisted  of  a  drachm  of  sodium 
chloride,  6  grains  of  potassium  chloride,  3  grains  of  sodiiun  phos- 
phate, 20  grains  of  sodium  carbonate,  and  2  drachms  of  pure  alcohol 
to  a  pint  of  distilled  water.  Four  pints  were  introduced  at  a  time,  at  a 
temperature  of  about  110°,  the  transfusion  taking  about  half  an  hour. 

My  own  impression  as  to  the  use  of  these  saline  solutions  alone  is 
that  their  benefit  is  fugitive,  but  in  this  I  attach,  perhaps,  too  much 
importance  to  two  cases  in  which,  some  years  ago,  I  injected  a  saline 
solution  analogous  to  that  above  given  in  ha?morrhage  after  amputa- 
tion of  the  thigh.  About  6  ounces  were  used  in  one  case,  and  about 
10  or  12  in  the  other.  The  patients  were  actually  moribund  on  each 
occasion.  Both  rallied  after  the  transfusion,  but  both  ultimately 
sank,  in  the  one  case  eighteen  hours,  in  the  other  about  ten,  having 
elapsed  since  the  transfusion. 

It  has  been  suggested  that  some  saline  solutions  which  have  the 
power  of  delaying  the  coagulation  of  blood — e.g.,  sodium  phosphate 
— should  be  added  to  the  blood  before  it  is  transfused.  Dr.  Hicksf 
brought  this  method  before  the  profession,  having  found  experiment- 
ally on  dogs  that  blood  mixed  with  sodium  phosphate,  after  being 
kept  out  of  the  system  for  some  time,  could  be  injected  back  into  the 
animal  without  any  detriment.  He  therefore  hoped  that  this  plan 
might  be  useful  where  there  is  no  time  for  defibrinating,  or  where  the 
quantity  of  blood  obtainable  is  so  small  as  to  render  defibrination 
difficult.  Dr.  Hicks  recommends  a  solution  of  3  ounces  of  the  fresh 
sodium  phosphate  dissolved  in  a  pint  of  water,  using  one  part  of  the 
solution  to  three  parts  of  blood,  and  injecting  from  6  to  8  ounces  of 
the  combined  fluid,  this  being  done  very  slowly  and  at  intervals  if 
the  heart's  action  is  embarrassed  by  the  use  of  more  than  2  ounces  at 
a  time.     Prof.  Schafer,J  who  investigated  the  subject  of  transfusion 


*  London  Hosp.  Reports,  vol.  iii.  p.  132. 
f  Guy's  Hosp.  Reports,  vol.  xiv.  p.  1. 
X  Obst.  Trans.,  vol.  xxi. 


TRANSFUSION.  89 

scientifically  for  the  Obstetrical  Society,  considered  that  this  solution 
was  too  strong,  and  certain  to  kill  the  blood  corjiuscles. 

There  is  one  more  method  of  transfusion,  or  rather  of  re-infusion, 
which  has  been  used  lately  by  the  Edinburgh  surgeons — viz.,  Dr. 
Duncan"!^  and  Messrs.  Annandale  and  Cotterillf — and  which,  being 
especially  adapted  to  amputation  cases,  is  of  great  interest  to  the 
hospital  surgeon.  Dr.  Duncan  used  it  successfully  in  a  case  of  am- 
putation of  the  thigh  for  a  railway  injury.  The  patient,  who  had  lost 
so  much  blood  before  the  operation  that  it  was  difficult  to  say  whether 
he  was  alive  or  dead  after  the  arteries  were  tied,  made  a  good  recovery 
after  the  injection  of  the  3  ounces  of  blood  which  he  had  lost  during 
the  operation  mixed  with  solution  of  sodium  phosphate — in  all,  about 
8  ounces  being  thrown  into  the  femoral  vein. 

Dr.  Duncan's  method  is  as  follows  : 

For  introduction  into  the  vein,  a  short  glass  tube,  of  the  size  of  a 
No.  6  catheter,  having  a  pen-shaped  point,  is  used.  To  its  otlier  end, 
slightly  bulbous,  about  2  inches  of  india-rubber  tubing  are  attached. 
A  simple  glass  syringe,  holding  4  ounces,  whose  nozzle  fits  the 
tubing,  is  perfectly  effective,  the  temperature  being  kept  up  with  boric 
lint  wrung  out  of  hot  water.  A  graduated  glass  vessel,  kept  floating 
in  warm  water,  contains  the  solution  of  sodium  phosphate  and  re- 
ceives the  blood. 

All  instruments  are  washed  in  aseptic  solutions.  The  most  con- 
venient vein  being  selected  on  the  face  of  the  stump,  the  glass  point 
is  inserted  and  a  catgut  ligature  put  round  it.  While  the  process  of 
ligaturing  the  arteries  is  going  on,  the  blood  is  caught  by  one  assist- 
ant, who  adds  the  soda  solution  as  required,  and  is  slowly  injected 
by  another. 

The  solution  of  sodium  phosphate  was  one  of  5  per  cent.,  one  part 
of  the  solution  being  added  to  three  parts  of  blood.  A  slightly  larger 
proportion  was  frequently  used  in  the  amputation  cases. 

About  five  minutes  were  occupied  in  injecting  the  8  ounces,  and,  in 
a  case  of  amputation  of  the  hip,  16  ounces  were  injected  in  about 
fifteen  minutes,  without  any  disturbance,  and  with  a  good  result. 

Dr.  Duncan  points  out  that  the  process  of  re-injecting  the  patient's 
own  blood  is  incompatible  with  the  use  of  spray  or  irrigation  during 
the  operation.  In  most  cases,  however,  the  use  of  the  germicide  may 
safely  be  delayed  till  near  the  end  of  the  operation,  as,  with  pure 
hands  and  instruments,  the  risk  from  the  air  is  trifling,  and  'is  not 
Avorth  considering  when  a  patient  is  in  imminent  danger  from  ha'mor- 
rhage  or  collapse. 

*  Brit.  Med.  Journ.,  1886,  vol.  1.  p.  192. 
t  Ibid.,  vol.  ii.  October  2. 


90  OPERATIONS    ON   THE    UPPER    EXTREMITY. 

The  same  apparatus  was  thus  used  in  a  case  of  i^ernicious  antemia 
by  Dr.  Duncan: 

A  vein  in  the  arm  of  tlie  receiver  was  exposed,  and  under  it  a  double 
thrend  of  catgut  passed.  Blood  was  thei;  drawn  from  the  donor  into 
a  dish  containing  the  sodium  phosphate,  Avith  which  it  was  gently 
mixed  by  means  of  a  glass  rod.  While  an  assistant  fitted  the  syringe, 
the  exposed  vein  of  the  receiver  was  opened,  the  lower  thread  of  cat- 
gut was  gently  pulled  upon  to  prevent  bleeding.  The  tube  was  now 
inserted,  the  upper  thread  tied  round  it  with  one  knot,  and  the  lower 
definitely  secured  and  cut  short.'  The  blood  was  next  slowly  injected, 
the  tubing  being  pinched  when  the  syringe  required  to  be  refilled. 
The  upper  catgut  was  finally  tied  and  cut  short  when  the  operation 
M^as  completed,  and  the  little  wound  was  stitched  up. 

Arterial  Transfusion. — While  transfusion  into  veins  is  in  prac- 
tice, on  the  whole,  the  most  generally  convenient  and  applicable 
method,  the  above  is,  theoretically,  so  superior  that  it  deserves  atten- 
tion. Prof.  Schafer  (loc.  supra  cit.)  recommends  the  following  method 
to  be  used  in  the  dorsalis  pedis  artery,  which,  for  the  sake  of  com- 
pleting the  subject,  may  be  mentioned  in  this  place : 

The  arteries  of  each  are  first  to  be  exposed  and  separated  from  their 
sheath  for  about  f  inch.  The  distal  ends  of  the  exposed  portions  of 
arteries  in  both  are  then  tied,  ligatures  are  placed  loosely  round  the 
upper  ends  also,  and  these  upper  ends  secured  by  spring  clips.  The 
transfusion  apparatus  itself  consists  simply  of  an  india-rubber  tube 
having  a  glass  cannula  at  each  end.  The  cannula  has  a  tajjering 
bevelled  end,  grooved  to  hold  the  ligature.  One  of  the  cannula?  is 
tied  into  the  artery  of  the  donor,  the  otlier  into  that  of  the  receiver, 
the  ends  of  both  being  directed  towards  the  heart.  The  clii:)s  are  then 
opened  for  about  a  minute,  or  a  little  longer  if  it  seem  desirable. 
Both  arteries  are  then  to  be  tied  just  aliove  the  clips,  and  finally  the 
cannula?  are  to  be  cut  out,  together  with  the  pieces  of  artery  into 
which  they  are  tied. 

Advantages  of  Arterial  Transfusion. 

1.  The  blood  transfused  is  oxygenated. 

2.  Any  clots  produced  are  washed  into  the  peripheral  arteries  of 
the  foot,  instead  of  into  those  of  the  lungs. 

3.  The  arterial  tension  of  the  patient  is  more  quickly  raised,  and 
the  tendency  to  s^aicope  thus  more  rapidly  averted,  than  when  the 
blood  is  thrown  into  a  vein. 

Disadvantages  of  Arterial  Transfusion. 

1.  An  artery  is  more  difficult  to  find  and  deal  with,  especially  in 
cases  of  hurry  and  emergency,  than  a  superficial  vein. 

2.  Emboli,  if  produced,  and  carried  into  the  peripheral  arteries,  may 
produce  gangrene  of  the  part. 


LIGATURE    OF    BRACHIAL    AT    BEND    OF    ELBOW.  91 

3.  It  is  a  more  serious  operation  for  the  donor  at  the  time,  and 
requires  him  to  be  more  careful  later  on. 

4.  An  artery  thus  used  is  only  available  once. 

Risks  and  Dangers  of  Transfusion. — Amongst  these  are : 

1.  Emboli  and  their  results. 

2.  Evidence  of  blood  being  thrown  in  too  rapidly  for  the  system  of 
the  receiver — e.g.,  headache,  flushing,  prsecordial  oppression,  etc.  ' 

3.  Perhaps  septic  absorption,  if  the  blood  has  been  exposed  too 
long,  or  if  milk  is  used  without  precautions  to  purify  it. 

4.  Many  of  the  risks  already  given  under  the  head  of  venesection 
(p.  82)  will,  of  course,  be  present  here  also. 

LIGATURE  OF  THE  BRACHIAL  ARTERY  AT  THE 
BEND  OF  THE  ELBOW  (Fig.  17). 

This  operation,  common  enough  fifty  years  ago  owing  to  the  fre- 
quency of  bleeding  and  the  facility  with  which  the  brachial  artery 
was  wounded,  will  be  briefly  described  here. 

Indications. — (1)  Wound  of  artery,  especially  after  bleeding.     (2) 
Traumatic  arterio- venous  aneurism,  also  occurring  after  bleeding. 
Guide. — The  inner  side  of  the  biceps  tendon. 
Relations:  In  Front. 

Skin;  fasciae;    bicipital  fiisciee;  median  basilic 
vein.      Branches    of    internal   and    external 
cutaneous  nerve. 
Outside.  Inside. 

Biceps  tendon.  Bnicliial  artery  Median  nerve. 

■\r^„„  ^^,^^„„  at  bend  of  elbow.  -tt 

Vena  comes.  Vena  comes. 

Behind. 

Brachialis  anticus. 

Operation  CFig.  17). — The  limb  being  steadied  with  the  elbow 
slightly  flexed,  the  site  of  the  biceps  tendon  should  be  defined,  and 
also  that  of  any  large  veins,  by  making  pressure  a  little  above  the 
proposed  site  of  ligature.  An  incision  about  2  inches  long  is  then 
made,  a  little  to  the  inner  side  of  the  biceps  tendon,  through  the 
superficial  fascia  carefully,  so  as  to  avoid  the  median  basilic  vein  and 
its  companion,  the  internal  cutaneous  nerve.  The  deep  fascia  is  then 
divided  on  a  director,  this  and  the  semilunar  fascia  of  the  biceps 
which  strengthens  it  being  interfered  with  as  little  as  possible.  The 
artery,  with  its  venae  comites,  lies  directly  underneath.  The  needle 
should  be  passed,  after  the  veins  are  separated  and  the  artery  cleaned, 
from  within  outwards,  so  as  to  avoid  the  median  nerve. 

In  the  case  of  traumatic  arterio-venous  aneurism  resisting  other 


92  OPERATION'S    ON    THE    UPPER    EXTREMITY. 

treatment,  the  old  operation  of  placing  double  ligatures*  will  be  pre- 
ferable to  the  Hunterian  one,  which  runs  the  risk  of  overlooking  the 
possibility  of  a  rather  higher  division  than  usual  of  the  brachial  into 
radial  and  ulnar.  If  much  haemorrhage  is  expected,  the  brachial 
should  be  compressed  about  the  middle  of  the  arm  with  an  Esmarch, 
or  the  vessel  controlled  by  a  reliable  assistant.  The  median  basilic 
vein  will,  in  such  cases,  be  often  found  much  dilated  by  the  entrance 
of  arterial  blood.     In  others  it  has  been  obliterated. 

This  operation  at  the  bend  of  the  elbow  should  always  be  performed 
with  the  utmost  carefulness  at  the  time  and  pains  taken  with  the 
after-treatment,  so  as  to  ensure  the  minimum  of  disturbance  and  the 
smallest  amount  of  cicatrix,  and  thus  to  interfere  as  little  as  possible 
with  the  movements  of  the  elbow. 


CHAPTER  V. 
OPERATIONS  ON  THE  ARM. 

LIGATURE  OF  BRAOHIAL  ARTERY  (Fig.  31). 

This  is  performed  (a)  in  the  middle  of  the  arm,  and,  much  more 
rarely,  (b)  at  the  bend  of  the  elbow,  the  operation  last  described. 
(a)  In  Middle  of  Arm  (Fig.  31). 
Indications. 

1.  Chiefly  wounds  of  palmar  arch,  resisting  pressure  (p.  37). 

2.  Wound  of  the  artery  itself  by  penknife,  bayonet,  bullet,  etc. 

3.  Gunshot  wound  of  the  elbow,  leading  to  secondary  haemorrhage, 
resisting  other  treatment. 

4.  Wound  of  one  of  the  arteries  of  the  forearm,  when  hcemorrhage 
has  occurred  from  a  wound  of  one  of  these  and  the  parts  are  in  a 
sloughy  condition.  In  the  year  1882  a  patient  came  under  my  care 
for  secondary  haemorrhage  from  a  wound  of  the  forearm,  inflicted  by 
the  bursting  of  a  gun  in  rook-shooting.    The  parts  were  much  swollen 

*  Here  ligatures  will  be  required  above  and  below  the  communication  with  the 
vein  in  the  case  of  aneurismal  varix,  and  above  and  below  the  sac  if  the  surgeon  is 
dealing  with  a  varicose  aneurism,  it  being  understood  that  palliative  treatment  has 
not  sufficed,  and  that  pressure,  applied  locally  and  on  the  main  trunk  above,  or  by 
means  of  Esmarch's  bandage,  has  failed.  If  ligature  is  decided  upon,  it  will  be  better 
(the  artery  being  commanded  above)  to  open  the  sac,  and  thus  find  the  apertures  into 
the  artery  by  the  aid  of  a  director.  As  Mr.  Holmes  {System  of  Surgery,  vol.  iii.  p.  92) 
points  out,  the  other  plan  of  attempting  to  find  and  tie  the  artery  without  opening  the 
eac  presents  these  difficulties  —viz.,  that  the  artery  is  surrounded  by  dilated  and  closely 
packed  veins,  and  that  below  the  sac  it  is  of  small  size. 


LIGATURE    OF    BRACHIAL    IN    THE    ARM.  93 

and  sloughy ;  the  uhiar  artery  in  its  middle  third,  from  which  the 
haemorrhage  was  coming,  was  greenish  in  color,  and  apparently  not  in 
a  condition  to  hold  a  ligature.  A  good  recovery,  with  no  further 
haemorrhage,  took  place  after  ligature  of  the  brachial  in  the  middle  of 
the  arm.  In  1885  I  had  occasion  again  to  tie  this  artery  for  haemor- 
rhage occurring  repeatedly  a  few  days  after  a  suppurating  palmar 
bursa  had  been  opened  in  the  usual  way,  above  and  below  the  ante- 
rior annular  ligament.     The  patient  recovered  with  a  Aveakened  limb. 

5.  Traumatic  aneurism. 

6.  Spontaneous  aneurism.  As  is  well  known,  spontaneous  aneurisms 
are  very  rare  in  the  upper  extremity,  and  usually  associated  with  car- 
diac disease.  Treatment  here  should  not  be  too  active  (see  below) ; 
ligature  should  only  be  thought  of  where  the  aneurism  is  rapidly  in- 
creasing or  causing  painful  pressure  upon  a  nerve.  Traumatic  aneu- 
rism is  decidedly  under  the  influence  of  pressure.  If  this  fails,  it  is 
a  question  if  the  old  operation  is  not  superior  to  the  Hunterian,  for 
the  sac  is  often  imperfect.* 

Dr.  Holt  (Amer.  Journ.  Med.  Sci,  April,  1882)  only  succeeded  in  col- 
lecting thirteeii  cases  of  spontaneous  aneurism  of  the  brachial  artery. 
From  his  paper  he  concludes  that  pressure  should  always  be  tried 
first.  This  is  more  likely  to  be  successful  in  aneurisms  low  down  in 
the  brachial  artery  than  in  those  in  its  upper  third,  as  pressure  is 
more  easily  applied  in  the  former  case,  owing  to  the  less  close  relation 
of  nerves  to  the  artery.  Amongst  these  cases  is  the  following  one, 
which  is  of  much  interest.  It  occurred  in  1857.  It  is  probable  that 
antiseptic  precautions  will  enable  the  surgeon  to  deal  successfully 
with  spontaneous  aneurism  in  the  upper  extremity,  even  when  asso- 
ciated with  cardiac  disease.  Aneurism  of  left  brachial  at  its  middle ; 
ligature  of  the  brachial  at  upper  third  ;  secondary  haemorrhage ;  liga- 
ture of  the  axillary  ;  cure.  A  butcher,  aged  thirty-two,  had  a  tumor, 
the  size  of  a  small  hen's  egg,  at  middle  of  the  left  brachial  artery.  It 
was  steadily  increasing.  The  patient  had  valvular  disease  and  great 
cardiac  hypertrophy.  The  brachial  was  tied  in  its  upper  third  ;  the 
aneurism  shrunk  to  a  small  liard  lump,  without  pulsation ;  the  liga- 
ture did  not  come  away  ;  and,  on  the  sixteenth  day,  with  the  thread 
still  hanging,  the  patient  butchered  a  calf.  ■  A  few  days  afterwards  he 
called  attention  to  a  rapidly  forming  tumor  just  above  the  ligature. 
Ligature  of  the  axillary  was  advised,  but  refused.  Two  weeks  later 
the  surgeon  was  called  for  haemorrhage,  the  false  aneurism  having 
burst.  The  axillary  was  then  tied  in  its  lower  third,  the  ligature  came- 
away  properly,  and  the  artery  between  the  ligatures,  as  well  as  the 
aneurism,  was  completely  obliterated.  The  patient  died  six  months- 
later  of  dropsy. 

*  Holmes,  Eoy.  Cull.  Surg.  Lect ,  Lancet,  October  2o,  1873. 


94 


OPERATIONS    ON    THE    UPPER    EXTREMITY. 


Line. — From  the  junction  of  the  middle  and  anterior  thirds  of  the 
axilla,  along  the  inner  edge  of  coraco-brachialis  and  biceps,  to  the 
middle  of  the  elbow  triangle.  This  line  is  of  especial  importance 
when,  owing  to  swelling,  etc.,  the  edge  of  the  biceps  is  difficult  to 
make  out. 

Guide. — The  above  line  and  the  inner  edge  of  biceps. 

Relations  in  arm  :  In  Front. 

Skin ;  fasciae ;  branches  of  internal  and  external 

cutaneous  nerves. 
Median  nerve*  (about  centre  of  arm). 

Inside. 
Ulnar  nerve. 

Internal  cutaneous  nerve. 
Vena  comes. 


Outside. 
Coraco-brachialis  (above) 
Biceps. 
Vena  comes. 


Brachial 

artery 

in  arm. 


Basilic  vein,  superficial  to 
deep  fascia  in  lower  half, 
beneath  it  above,  usually. 
Behind. 

Triceps  (middle  and  inner  heads);  coraco- 
brachialis  ;  brachialis  anticus. 
Musculo-spiral  nerve  and  superior  profunda 
artery  (above). 
Collateral  Circulation. 

(a)  If  the   ligature  be  placed   above  the  superior   profunda,  the 
vessels  chiefly  concerned  will  be  : 

Above.  Below. 

The  subscapular ]  .,,  rni  •  r      i 

r^,       .  r,         r  with  ihe  superior  proiunda. 

The  circumiiex   j 

(&)  If  the  ligature  be  placed  below  the  superior  profunda  : 

Above. 


The  superior  profunda     with 


Below. 
The  radial  recurrent. 
The  posterior  ulnar  recurrent, 
"j   The  interosseous  recurrent. 
I   The  anastomotica  magna, 
(c)  If  the  ligature  be  placed  below  the  inferior  profunda : 


Above. 

The  superior  profunda 
The  inferior  profunda 


with 


Below. 
The  radial  recurrent. 
The  ulnar  recurrents. 
The  interosseous  recurrent. 
The  anastomotica  maana. 


*  In  one  out  of  every  six  cases,  the  median  nerve  lies  under  the  artery:  Skey,  loc. 
supra  cit.,  p.  269. 


LIGATURE    OF    BRACHIAL    IN    THE    ARM.  95 

Abnormalities. — These  are  so  far  from  infrequent''^  that  the 
surgeon  must  be  prepared  for  the  following: 

1.  The  artery  being  in  front  of  the  nerve  (foot-note,  p.  94  \ 

2.  A  high  division  of  the  artery.  According  to  Mr.  Quain,  in  one 
out  of  every  five  cases  there  were  two  arteries  instead  of  one  in  some 
part,  or  in  the  whole,  of  the  arm.  The  point  of  bifurcation  is  thus 
described  by  Gray  :  "  It  is  most  frequent  in  the  upper  part,  less  so  in 
the  lower  part,  and  least  so  in  the  middle,  the  most  usual  point  for 
the  application  of  a  ligature ;  under  any  of  these  circumstances,  two 
large  arteries  Avould  be  found  in  the  arm  instead  of  one.  The  most 
frequent  (in  three  out  of  four) -of  these  peculiarities  is  the  high  division 
of  the  radial.  That  artery  often  arises  from  the  inner  side  of  the  bra- 
chial, and  runs  parallel  with  the  main  trunk  to  the  elbow,  where  it 
crosses  it,  lying  beneath  the  fascia;  or  it  may  perforate  the  fascia,  and 
pass  over  the  artery  immediatel}^  beneath  the  integument. "f 

3.  The  artery  may  be  partially  covered  by  a  muscular  slip  given  off 
from  the  pectoralis  major,  biceps,  coraco-brachialis,  or  brachialis 
anticus. 

4.  One  or  more  slender  vasa  aberrantia  may  be  met  with  in  the 
arm,  passing  from  the  axillary  or  the  brachial  to  one  of  the  arteri&s 
in  the  forearm. 

Operation  (Fig.  31). — The  arm  being  extended  and  abducted  from 
the  side,  with  the  elbow-joint  flexed  and  supported  X  by  an  assistant, 
the  surgeon,  sitting  between  the  limb  and  the  trunk, §  makes,  be- 
ginning from  below  or  above  as  is  most  convenient,  an  incision  2i 
inches  in  length  along  the  inner  border  of  the  biceps,  going  through 
the  skin  and  fascia?,  and  exposing  just  the  innermost  fibres  of  this 
muscle. 1 1  This  is  then  drawn  outwards  with  a  retractor,  the  median 
nerve  next  found  and  drawn  inwards  or  outwards  with  a  strabismus 
hook,  and  the  artery  defined  and  sufficiently  cleared,  when  the  liga- 

*  Numerous  instances  of  tliese  are  figured  by  Mr.  Reeves  in  tlie  Appendix  to  his 
Human  Morphology^  vol.  i.  p.  692  et  seq. 

t  The  possibility  of  this  superfi.cial  position  of  the  radial  oi-  ulnar  should  always  be 
remembered  when  venesection  at  the  elbow  is  about  to  be  performed.  See  also  the 
foot-note,  p.  80. 

X  Mr.  Heath  has  pointed  out  {Operative  Surcjery,  p.  18)  that  if  the  arm  when  at  a 
right  angle  to  tiie  body  be  allowed  to  rest  upon  the  table,  the  triceps  is  pushed  up,  and 
displacing  the  parts  may  bring  into  view  the  inferior  profunda  and  the  ulnar  nerve, 
instead  of  the  brachial  and  the  median  nerve. 

§  This  is,  to  my  mind,  a  much  more  comfortable  position  than  standing  on  the  outer 
side  and  looking  over. 

II  Authorities  differ  as  to  this  step.  I  strongly  advise  the  operator  to  avail  liimself 
of  this  guide.  If  it  be  done  carefully,  and  the  wound  kept  sweet  afterwards,  it  can  do 
no  harm.  The  fibres  of  the  muscle  are  a  distinct  help,  and  (as  stated  below)  ligature 
of  this  artery  is  not  as  easy  a  one  as  it  would  appear. 


96  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

ture  is  passed  from  the  nerve.  In  doing  this  the  basilic  vein  and  the 
vena3  comites,  which  increase  in  size  as  they  ascend,  must  ))e  carefully 
avoided. 

I  would  point  out  that  the  brachial  artery  is  by  no  means  so  easy 
a  vessel  to  tie  as  might  be  supposed  from  its  superficial  position. 
This  is  especially  the  case  when  the  artery  is  concealed  by  the  median 
nerve  at  the  point  where  it  is  sought,  and  when  its  beat  is  feeble  and 
the  vessel  itself  small  and  but  little  distended  after  repeated  hemor- 
rhage lower  down.* 

AMPUTATION  OF  ARM  (Figs.  28,  29,  and  30). 

Indications. — Amongst  these  are  : 

1.  Accidents,  e.g.,  compound  fractures,  machinery  accidents,  etc., 
which  do  not  admit  of  any  part  of  the  forearm  being  saved,  or  of 
amputation  of  the  elbow. 

The  advisability  of  amputation  in  these  cases  is  discussed,  once  .for 
all,  in  the  chapter  on  the  antiseptic  treatment  of  compound  fractures. 

2.  New  growths  involving  the  forearm,  and  not  admitting  of  ex- 
tirpation. 

3.  Disease  of  the  elbow-joint  not  admitting  of  excision,  or  in  which 
this  operation  has  failed  (p.  67). 

4.  Gunshot  injuries  of  upper  part  of  forearm,  elbow,  and  arm  not 
admitting  of  conservative  treatment  or  excision. 

So  inestiaiable  is  the  value,  even  when  only  partial,  of  the  hand, 
and  so  good  are  the  results  of  conservative  treatment  and  secondary 
amj^utation,  that  the  tissues  must  be  almost  disorganized  for  the  sur- 
geon to  think  of  primary  amputation  here.f 

*  This  was  so  marked  in  the  second  of  the  two  ca>es  mentioned  at  p.  93,  tliat  on 
my  exposing  the  vessel,  several  bystanders  felt  certain  that  it  was  not  the  brachial, 
bnt  one  of  its  branches. 

t  Dr.  Otis  (Zoc.  supra  cit.  p.  916)  thns  sums  up  on  the  question  of  conservative  sur- 
gery, excision,  and  amputation  in  gunshot  injuries  of  the  elbow-joint:  "The  practical 
conclusions  that  appear  to  me  deducible  from  the  foregoing  investigations  are — (1) 
That  in  shot  wounds  in  young  healthy  subjects  attended  with  slight  injury  of  the  ar- 
ticular extremities  of  the  bones  of  the  elbow,  such  as  fractures  of  the  olecranon,  of  the 
outer  condyle,  or  of  the  trochlea,  without  much  splintering  and  without  lesion  of  the 
important  vessels  and  nerves,  it  is  justifiable  in  many  instances  to  attempt  an  expect- 
ant conservative  treatment,  keeping  the  injured  extremity  in  entire  rest,  after  removing 
any  detached  fragments  or  foreign  bodies,  in  a  semi-prone  and  very  flexed  position, 
employing  ice  or  other  cold  applications.  If  the  inflammatory  action  becomes  intense, 
the  wound  should  be  freely  enlarged,  and  the  joint-cavity  freely  laid  open,  and  easy 
escape  provided  for  the  altered  wound  secretions  by  position  and  drainage-tubes.  The 
strength  should  be  sustained  l)y  a  tonic  regimen,  and  when  the  inflammatory  stage  has 
completely  abated,  and  not  before,  if  healing  is  slow,  secondary  excision  or  amputation 
may  be  hopefully  resorted  to.     Unless  all  the  favoraljle  conditions  mentioned  are  pres- 


AMPUTATION    OF   THE    ARM.  97 

Amongst  the  special  conditions  which  will  have  to  be  considered 
are  the  size  of  the  projectile, 'the  gravity  of  the  laceration  of  the  soft 
parts,  the  amount  of  longitudinal  splintering  of  the  bones,  the  extent 
of  lesions  to  the  vessels  and  nerves,  and  the  degree  to  which  suitable 
conservative  measures  can  be  adopted  in  the  absence  of  hospital 
facilities  or  of  easy  transportation.* 

If  the  surroundings  of  the  surgeon  and  patient  admit  of  it,  at- 
tempts will  nowadays  be  made  to  suture  the  nerve  ends,  especially 
when  only  one  or  two  of  the  chief  trunks  are  involved.  Whether  the 
old  doctrine,  that  shot-fracture  of  the  humerus  Avith  wound  of  the 
brachial  artery  imperatively  indicates  amputation,  is  correct  must 
remain  uncertain.  Dr.  Otis  (loc.  mpra  cit.  p.  674)  writes  on  this  point : 
"  I  confess  that  the  evidence  in  the  reported  cases  appears  to  me  in- 
sufficiently circumstantial  and  precise  to  decide  affirmatively  this 
controverted  point." 

Methods. 

i.  Skin-Haps  with  circular  division  of  muscle — (<()  antcro-posterior 
flaps,  (b)  lateral  flaps. 

ii.  Transfixion  flaps,  usually  antero-posterior. 

iii.  Skin  and  transfixion  flaps  combined. 

iv.  Circular. 

i.  Skin  Flaps  with  Circular  Division  of  Muscles.— This 

should  be  made  use  of  in  bulky  muscular  arms. 

(«)  AxTERO-POSTERioR  Flaps. — The  brachial  having  been  controlled,t 
the  limb  supported  at  a  right  angle  to  the  body,  and  the  surgeon, 
standing  outside  the  right  and  inside  the  left  limb,  with   finger  and 


ent  at  the  outset,  it  would  be  safer  to  resort  to  primary  excision  or  to  amputation.  (2) 
III  grape-shot  comminutions  with  lesions  of  the  principal  vessels  or  nerves,  ami)iita- 
tion  should  be  practiced  immediately  after  the  reception  of  the  injury.  (3)  In  severe 
shot  fracture,  without  extensive  lesion  of  the  soft  parts,  the  joint  sliould  be  freely  ex- 
posed by  a  longitudinal  posterior  incision,  and  the  full  extent  of  the  fracture  ascer- 
tained. Unless  there  is  extraordinary  Hssuring,  the  injured  joint  ends  sliould  then  be 
sawn  off  as  close  to  the  limits  of  injury  as  possible,  save  that  the  bones  of  tiie  forearm 
should  be  shortened  to  the  same  level.  If  the  splintering  extends  very  far,  or  if  there 
is  reason  to  believe  that  the  humeral  vessels  are  injured  though  not  wounded,  the 
incision  should  be  so  modified  as  to  convert  the  operation  into  an  amputation." 

*  On  this  point  Dr.  Otis  writes  (loc.  aiipra  cit.  p.  811),  "The  surgeons,  doubtless, 
sometimes  yielded  to  what  John  Bell  called  '  an  argument  of  necessity  as  well  as  of 
choice,  and  limbs,  that  in  happier  circumstances  might  have  been  preserved,  had 
often,  in  a  flying  army  or  a  dangerous  campaign,  to  be  cut  off,'  since  '  it  is  less  dread- 
ful to  be  dragged  along  with  a  neat  amputated  stump  than  with  a  swollen  and  fractured 
limb,  where  tlie  arteries  are  in  constant  danger  from  the  splintered  bones  '" 

t  With  an  Esmarch  usually  ;  in  amputation  high  up,  either  the  axiibiry  imist  be 
controlled  by  elastic  tubing  applied  by  a  modification  of  the  method  given  at  p.  117, 
or  the  subclavian  must  be  controlled  bv  a  reliable  assistant. 


98  OPERATION'S    ON    THE    UPPER    EXTREMITY. 

thumb  of  left  liand  marking  the  site  of  intended  bone  section  (Fig. 
28),  enters  the  knife  on  the  side  of  tlie  liml)  farthest  from  him,  carries 
it  first  down  ii,  3.t,  or  4  inches,  according  as  he  is  going  to  make  one 
flap  longer  than  the  other  or  not,*  then  across  the  limb,  with  Avell- 
rounded  edges,  and  up  the  side  nearest  to  him  to  the  point  opposite 
to  that  from  which  the  incision  started.  Next,  passing  the  knife 
under  the  limb,  he  marks  out  a  posterior  flap,  usually  somewhat 
shorter  than  the  anterior.  These  flaps,  consisting  of  skin  and  fascise, 
are  then  divssected  up,  the  muscles  cut  through  at  the  flap-base  with 
a  circular  sweep,  and  the  bone  sawn  through  as  high  as  possible. 
Especial  care  should  be  taken  here,  as  in  forearm  amputations,  to 
divide  the  nerve-trunks  square  and  high  up.f 

(b)  Lateral  Flaps. — This  method  may  be  made  use  of,  one  flap 
being  cut  longer  than  the  other,  when  the  skin  is  n^ore  damaged  on 
one  side. 

The  surgeon,  standing  as  before,  marks  the  site  of  bone-section  by 
placing  his  left  forefinger  and  thumb,  not  now  on  the  two  borders  of 
the  arm,  but  on  the  central  j^oints  of  the  anterior  and  posterior  sur- 
faces of  the  liml).  Looking  over,  he  enters  his  knife  at  the  latter 
spot,  and  cuts  a  well-rounded  flap,  ending  at  the  thumb  on  middle 
of  the  anterior  aspect,  and  then,  from  this  point,  without  removing 
the  knife,  another  flap  is  marked  out  by  a  similar  incision  ending  at 
the  middle  of  the  back  of  the  arm.  The  flaps  are  then  dissected  up, 
and  the  operation  completed  as  in  the  method  already  given. 

ii.  Transfixion  Flaps,  usually  Antero-posterior( Fig.  27.)— 
In  an  arm  of  moderate  size,  or  in  cases  where  rapidity  is  required,  as 
in  warfare  or  in  cases  of  double  amputation,  this  method  may  be 
made  use  of.  The  surgeon,  standing  as  before, |  and  with  his  left  hand 
marking  the  flap  base,  and  lifting  up  the  soft  parts  in  front  of  the 
humerus  so  as  to  get  in  front  of  the  brachial  vessels,  and  thus  avoid 
splitting  them,  sends  his  knife  across  the  bone  and  in  front  of  the 
above  vessels,  and  makes  it  emerge  at  a  point  exactly  ojiposite ;  he 
then  cuts  a  well-rounded  flap,  about  3  inches  long,  with  a  c{uick  sawing 
movement,  taking  care,  after  he  feels  the  muscular  resistance  cease,  to 
carry  his  knife  on  a  little,  so  as  to  cut  the  skin  longer  than  the  muscles, 

*  If  the  flaps  are  cut  of  equal  length,  the  cicatrix  will  be  opposite,  and  perhaps  ad- 
herent to,  the  bone;  tills  is  very  nndesirable,  though  of  less  importance  in  a  stump  of 
tiie  upper  than  of  tlie  lower  extremity. 

f  In  an  amputation  which  passes  throngli  the  musculo  sjjiral  groove,  great  care 
must  be  taken  lo  divide  completely  the  nerve  lying  in  this,  before  the  bone  is  sawn. 
The  depth  of  this  groove  varies  much.  When  it  is  considerable,  the  nerve  may  easily 
escape  division  and  be  frayed  by  the  saw,  giving  rise,  if  overlooked,  to  a  most  painful, 
bulbous  end. 

X  In  Fig.  27  the  surgeon  is  supposed  to  be  standing  outside  the  left  arm. 


AMPUTATION    OF    THE    ARM. 


99 


the  knife  being  finally  brought  out  quickly  and  perpendicularly  to 
the  skin.  The  flap  being  then  lightly  raised,  without  forcible  retrac- 
tion, the  knife  is  then  passed  behind  the  bone  at  the  baee  of  the 
wound  already  made,  and  a  posterior  flap  cut  similar  to  the  anterior, 
but  somewhat  shorter.     Both  flaps  are  then  retracted,  any  remaining 

Fig.  27. 


(Fergusson.) 


muscvilar  fibres  divided  with  circular  sweeps  of  the  knife,  and  the 
bone  exposed  a  little  above  the  junction  of  the  flaps.  The  saw  is 
then  applied  after  careful  division  of  the  periosteum.  The  brachial 
artery  will  either  be  found  in  the  posterior  flap,  or  if,  as  both  flaj^s  are 


Fig.  28. 


made,  the  soft  parts  are  drawn  a  little  from  the  humerus,  the  main 
artery  and  nerves  will  be  left,  and  must  be  cut  square  with  the  circu- 
lar sweeps  of  the  knife. 

If  it  be  preferred,  lateral  flaps  can  be  made  by  transfixion,  one,  of 
course,  being  cut  longer  than  the  other  if  this  is  rendered  desirable  by 
the  condition  of  the  soft  parts. 


100  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

iii.  Combined  Skin  and  Transfixion  Flaps  (Fig.  28).— This, 
a  very  speedy  and  efficient  method,  may  be  made  use  of  here.  An 
anterior  flap  of  skin  and  fascia^  about  3  inches  long,  having  i^een 
marked  out  (p.  98)  and  dissected  up,  the  bulk  of  the  soft  parts  behind 
the  bone  are  drawn  a  little  away  from  it,  the  knife  passed  behind  the 
humerus,  and  a  posterior  flap,  somewhat  shorter,  cut  by  transfixion. 

iv.  Circular  (Fig.  29). — Owing  to  the  moderate  size  of  the  liml:), 
and  its  circular  shape,  this  is  the  place,  above  all  others,  where  this 
method  can  be  made  use  of,  especially  in  limbs  which  are  not  very 

Fig.  29. 


bulky.  Whether  he  make  use  of  it  in  after-life  or  no,  the  student 
should  always  perform  a  circular  amputation  here  on  the  dead 
subject. 

Standing  as  before,  or  on  the  outer  side  of  either  limb,  the  surgeon, 
with  his  left  hand,  draws  up  strongly  the  skin,  and  passes  his  knife 
under  the  arm,  then  above,  and  so  around  it,  till,  by  dropping  the 
point  vertically,  the  back  of  the  knife  looks  towards  him,  and  the  heel 
rests  on  the  part  of  the  arm  nearest  to  him.  A  circular  sweep  is  then 
made  round  the  limb,  the  completion  of  this  being  aided  by  the  assistant 
in  charge  of  the  limb,  who  should  rotate  it  so  as  to  make  the  tissues 
meet  the  knife.  A  cuff-like  flap  of  skin  and  fascia3*  is  then  raised,  for 
2i  or  3  inches,  with  light  touches  of  the  knife,  and,  having  been 
folded  back,  the  muscles  are  cut  through  close  to  the  reflected  skin.f 
The  cut  muscles  are  next  retracted  by  the  operator's  left  hand,  and 
the  remaining  soft  parts,  with  the  main  vessels  and  nerves,  are 
severed  clean  and  square. ;{:  The  bone  is  then  freed  for  I  inch,  and 
the  periosteum,  having  been  divided,  is  sawn  tlirough  as  high  as 
possible. 

*  See  p.  61. 

t  By  some  it  is  advised  to  cut  tlie  biceps  nttlier  longer  tlinn  the  rest,  owing  to  its 
retracting  more,  as  it  is  not  attached  to  the  humerus. 

X  See  the  remarits  (foot-note,  p.  98)  on  the  importance  of  securing  thorough  and 
clean  division  of  the  musculo  spiral  nerve  when  tiie  aniputation  passes  through  the 
groove. 


EXCISION    OF    THE    SHAFT    OF    THE    HUMERUS.  lOl 

EXCISION  IN   CONTINUITY  OF   THE   SHAFT    OF   THE 

HUMERUS. 

This  operation  has  been  especially  discussed  in  its  application  to 
gunshot  wounds.  By  the  term  "  excision  in  continuity,"  deliberate 
removal,  the  periosteum  being  preserved  as  far  as  possible,  of  portions 
of  the  shaft  of  the  humerus — e.g.,  2-6  inches — is  meant;  and  from  it 
such  operations  as  incision  aiid  removal  of  splinters,  operations  for 
necrosis  and  for  pseudo-arthrosis,  should  be  excluded. 

Dr.  Otis*  thus  writes  of  this  operation :  "  I  cannot  discern  that  the 
experience  of  the  war  lends  any  support  to  the  doctrine  of  the  justi- 
fiability of  operations  of  this  nature  except  in  very  exceptional  cases. 
The  numerical  returns,  and  the  necessarily  abbreviated  summaries, 
may  appear,, at  first  glance,  to  represent  the  results  in  a  favorable 
light,  but  a  more  precise  analysis  reveals  most  lamentable  conclu- 
sions  The  mortality  rate  is  nearly  double  that  observed  in  the 

cases  treated  b}^  expectant  measures,  and  more  than  12  per  cent, 
higher  than  the  fatality  in  a  larger  series  of  primary  amputations  in  the 
upper  third  of  the  arm.  Moreover,  in  the  477  cases  of  recovery  there 
were  no  less  than  99  instances  in  which  'no  bony  union '  was  reported, 
and  65  others  recorded  as  examples  of  'fiilse  joint.'  There  were  also 
amongst  the  cases  reported  as  'successful'  37  instances  of  consecutive 
amputation  of  the  arm.  Recourse  was  had  to  ulterior  exarticulation 
or  amputation  in  64  patients,  of  whom  27  perished. 

'"Such  evidence  warrants  the  assertion  that  early  excision  in  the 
continuity  of  the  humerus  after  injury  can  seldom  be  justifiable,  a 
conclusion  at  which  European  surgeons  had  already  arrived  from  the 
experience  of  the  Schleswig-Holstein  and  Danish  wars,  and  which 
had  been  confirmed  by  more  recent  observations.  The  coaptation  of 
the  resected  ends  of  the  bones  by  silver  wires  was  sometimes  prac- 
ticed, with  few  illustrations  of  favorable  results.  Examination  of  the 
details  of  many  of  the  formal  primary  excisions  in  the  shaft  strengthens 
the  impression  that  they  were  for  the  most  part  unnecessary  and  in- 
jurious." 

Causes  of  Failure  after  Excision  of  the  Humerus  in  Con- 
tinuity.— Amongst  these  are  : 

1.  Osteo-myelitis  and  pyaemia. 

*  ]\[ed.  and  Surg.  Hist  of  the  War  of  the  Rebellion,  pt.  ii.  p.  095  el  seq.  In  Circular 
No.  3,  p.  223,  seven  "snccessfiil"  cases  are  briefly  reportecl.  In  one  of  tliese,  two 
months  after  the  removal  of  3  inches  of  the  shaft  (the  operation  being  performed  for 
caries  a  year  after  a  gunshot  injury),  bony  union  had  taken  place,  the  functions  of  the 
hand  and  arm  were  well  performed.  The  patient  could  lift  8  or  10  lbs.,  and  the  arm 
was  still  becoming  stronger.  The  bone  renewed  is  said  to  have  been  completely 
denuded  of  its  periosteum  in  its  entire  circumference. 


]02  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

2.  Secondary  haemorrhage. 

3.  Secondary  necrosis. 

4.  Non-union,  leading  to  a  limb  which  dangles^  or  is  Hail-like,  and 
is  more  or  less  useless  in  spite  of  a  support. 

While  excision  in  continuity  of  the  humerus  is  to  be  condemned 
as  a  primary  operation,  and  while  the  same  operation  performed  sec- 
ondarily for  necrosis  may  lead  to  a  limb  which  is  of  little  use  without 
an  artificial  support,  the  following  case  of  Dr.  Macewen'sf  shows  what 
ingenuity  and  perseverance  may  effect  in  such  cases,  and  proves  that 
detached  j^ortions  of  bone  deprived  of  their  j^eriosteum  are  capable  of 
living  and  growing  after  transplantation: 

A  boy,  aged  two,  had  complete;};  necrosis  of  the  shaft  of  his  right 
humerus  after  suppurative  periostitis.  The  necrosed  bone  was  re- 
moved about  nine  weeks  after  the  onset  of  the  periostitis,  leaving 
the  layer  of  granulations  covering  the  periosteum  intact,  and  forming 
a  tube,  which  was  kept  patent  by  dressings  suitably  inserted  until  the 
whole  space  had  granulated  up.  No  bone  grew  from  the  periosteum, 
except  a  small  part  next  the  proximal  epiphysis,  where,  at  the  out- 
set, the  periosteum  was  found  covered  by  plaques  of  adherent  osseous 
tissue.  From  the  whole  of  the  remainder  there  was  no  osseous  de- 
position, the  result  being  a  flail-like  arm.  Fifteen  months  subse- 
quently he  returned  to  the  Glasgow  Royal  Infirmary,  his  parents 
desiring  that  the  arm  should  be  removed,  it  being  worse  than  useless, 
inasmuch  as  he  required  the  other  hand  and  arm  to  look  after  the 
flail-like  one,  which  was  constantly  dangling  in  the  way.  The  con- 
dition of  the  arm  was  as  follows:  The  bone  had  not  increased  in 
length  since  he  left  the  hospital.  When  the  limb  was  allowed  to  hang 
b}'-  the  side,  the  measurement,  from  the  tip  of  the  acromion  process  to 
the  distal  extremity  of  the  humeral  shaft,  was  nearly  2  inches.  The 
proximal  fragment  was  conical,  and  tapering  from  the  rounded  head 
to  a  narrow  spike-like  extremity.  From  this  to  the  condyles  there 
was  a  complete  absence  of  bone,  there  being  nothing  but  soft  tissues 
in  the  gap.  The  muscular  power  was  good,  but  when  he  attempted 
to  raise  his  arm  a  contraction  of  the  muscles  took  place,  the  condyles 

*  There  is  a  good  illustration  of  this  result  in  Fijj.  506,  Inc.  supra  cit.,  p.  682.  Fur- 
ther details  are  needed  of  the  amount  of  use  made  of,  and  the  ultimate  advantage 
accruing  from,  the  ingenious  apparatus  of  Dr.  Hudson,  which  was  supplied  to  many  of 
these  cases.  In  one  (Circular  3,  p.  223),  the  arm  being  unreliable  owing  to  want  of 
leverage,  the  incipient  usefulness  of  this  apparatus,  supplied  two  3'ears  and  a  half  after 
the  injury,  is  stated  to  have  been  "highly  gratifying  and  efficacious." 

t  Annnis  of  Surgery,  vol.  vi.,  No.  4,  p.  301. 

X  Dr.  Macewen  points  out  that  it  is  probable  that  in  the  outset  of  this  case  the 
nutrient  artery  of  the  humerus  was  occluded  or  separated  in  the  intensity  of  the  sup- 
purating process.  The  periosteum  which  remained,  not  only  did  not  produce  bone, 
but  fifteen  months  later  appeared  to  have  been  completely  absorbed. 


EXCISION    OF    THE   SHAFT    OF    THE    PIUMERUS  103 

being  drawn  towards  the  proximal  extremity,  while  some  fibres 
of  the  deltoid  raised  the  spike-like  process  of  the  upper  portion, 
causing  it  to  project,  as  if  about  to  penetrate  the  skin.  Here  the 
action  ceased,  the  soft  parts  in  the  gap  appearing  like  a  rope  during 
the  muscular  contraction.  He  could  not  raise  his  forearm  to  his 
breast,  the  lever  and  fulcrum  needed  being  wanting.  It  was  deter- 
mined to  supply  these  by  transplantation  from  other  human  bones. 
In  the  wards  there  were  numerous  cases  of  marked  anterior  tibial 
curves,  from  which  wedges  of  bone  had  to  be  removed,  and  these  were 
used  as  transplants.  An  incision  was  made  into  the  upper  tliird  of 
the  humerus,  exposing  the  head  of  the  bone.  Its  extremity,  for  fully 
}  inch,  was  found  to  be  cartilaginous.  The  cartilaginous  spike-like 
process  was  removed,  leaving  there  a  portion  of  bone,  whicli  measured 

1  I  inch  from  the  tip  of  the  acromion.     From  this  point  a  sulcus,  about 

2  inches  long,  was  made,  downwards,  between  the  muscles.  The 
former  presence  of  bone  was  nowhere  indicated,  and  there  was  no 
vestige  of  periosteum,  and  the  sole  guide  as  to  the  correct  position  into 
which  the  transplant  was  placed  was  an  anatomical  one.*  Two 
wedges  of  bone  were  then  removed  from  the  tibia  of  a  patient,  aged 
six,  affected  with  anterior  curves.  The  base  of  these  osseous  wedges 
consisted  of  the  anterior  portion  of  the  tibia,  along  w4th  its  periosteum. 
After  removal  they  were  cut  into  minute  fragments  with  the  chisel, 
quite  irrespective  of  the  periosteum.  The  bulk  of  the  fragments  had 
no  periosteum  adhering  to  them,  they  having  been  taken  from  the 
interior  of  the  bone.  They  were  then  deposited  into  the  muscular 
sulcus  in  the  boy's  arm,  and  the  tissues  drawn  over  them  and  care- 
fulh'  adjusted.  The  wound  healed  without  pus  production.!  Two 
months  after,  a  portion  of  bone  1  inch  in  length  and  2  inch  in  thick- 
ness, was  found  firmly  attached  to  the  upper  fragment  of  the  humerus. 
In  moving  the  finger  from  the  head  of  the  bone  towards  the  graft,  the 
latter  could  be  easily  distinguished  by  the  sudden  increase  in  the 
breadth.  Now,  instead  of  the  former  sharp  spike,  the  upper  fragment 
ended  obtusely.  Two  other  wedges  of  bone,  of  larger  size  than  the 
first,  were  similarly  dealt  with  and  inserted  two  months  after  the  first. 
These  filled  up  the  gap  in  the  arm  to  the  extent  of  4t  inches,  the  arm 
then  measuring  6  inches  in  length.  Soon  the  utility  of  the  arm  was 
greatly  restored. 

Seven  years  afterwards  the  patient  was  seen  and  examined.  The 
shaft  of  the  humerus  was  found  to  have  increased  in  length  by  If 
inches,  being  now  71  inches  ;  it  had  increased  in  circumference  to  a 

*  I.e.,  the  only  guide  was  by  recognizing  the  relative  positions  wiiicli  tlie  muscles 
ought  to  occupy  towards  the  humerus. 

t  The  importance  of  this  statement,  and  its  effect  iii)on  the  very  happy  result  of  the 
cas3,  will  not  escape  tiie  reader. 


104  OPERATIONS   ON    THE    UPPER    EXTREMITY. 

marked  extent,  and  had  assumed  a  somewhat  irregular  shape.  The 
patient  could  use  his  arm  for  a  great  many  purposes — taking  his  food, 
adjusting  his  clothes,  and  in  many  games. 

In  some  remarks  on  this  case,  Dr.  Macewen  advances  the  following 
arguments  against  the  supposition  that  the  new  bone  grew  from  old 
periosteum:  (1)  If  any" of  this  had  existed  and  possessed  osteogenic 
power,  it  had  ample  time  to  reveal  itself  by  osseous  growth  during  the 
fifteen  months  which  had  elapsed  between  the  removal  of  the  dead 
bone  and  the  transi)lantation  of  the  new.  (2)  In  opening  the  sulcus 
between  the  muscles  for  the  reception  of  the  transi^lants,  no  perios- 
teum or  an3'thing  like  fibrous  membrane  Avas  seen.  (3)  The  growth 
of  the  bone  was  at  first  onh"^  commensurate  with  the  insertion  of  the 
transplants,  there  being  no  indication  of  any  osseous  growth  in  the 
vicinity  of  these  which  might  have  arisen  from  the  supposed  stimu- 
lation of  the  periosteum.  (4)  The  solid  humerus  still  retains  the 
irregularities  of  shape  which  the  transplants  were  permitted  to  assume 
in  the  tissues. 

OPERATIONS  ON  MUSCULO-SPIRAL  NERVE. 

Suture  of  this  nerve  after  injuries  to  it  in  different  parts  of  its  course 
is  referred  to  under  the  heading  of  "  Nerve-suture." 

There  is  another  lesion  to  which  this  nerve  is,  OAving  to  its  close 
connection  with  the  shaft  of  the  humerus,  occasionally  liable  after 
fracture  of  that  bone — viz.,  compression  by  callus.*  M.  Oilier  f  niany 
years  ago  recorded  a  case  of  this  kind  successfully  treated  by  surgery. 
A  man,  aged  twenty-two,  had  suffered  a  compound  fracture  of  the 
right  humerus,  through  the  musculo-spiral  groove.  Four  months 
later,  the  fracture  having  firmly  united,  the  extensors  of  the  wrist  and 
fingers  were  completely  paralyzed,  and  sensil)ility  along  the  course  of 
the  radial  was  much  diminished.  The  integrity  of  the  functions  of 
the  triceps  seemed  to  show  that  the  lesion  must  be  seated  below  the 
commencement  at  the  musculo-spiral  groove,  where  the  branches  to 
that  muscle  are  given  off.  M.  Oilier  concluded  that  the  nerve  was 
compressed  either  by  one  of  the  fragments  or  by  exuberant  callus. 
Prolonged  treatment  directed  towards  the  removal  of  the  callus  having 
failed,  the  patient  was  submitted  to  operation.  An  incision  having 
been  made  in  the  presumed  direction  of  the  nerve,  so  as  to  expose  it 
in  the  external  intermuscular  septum,  it  was  found  by  tracing  a 
branch  upwards.  A  gutter  was  next  cut  with  chisel  and  mallet  for  H 
inches  through  the  callus,  this  step  exposing  the  nerve,  swollen   and 

*  The  occasional  abundance  of  tliis  callus  may.  perhaps,  be  in  i)art  accounted  for 
by  the  great  thickness  of  the  periosteum  of  the  humerus. 

t  Syd.  Soc.  Blcn.  Betr.,  ]8t55,  1866,  p.  294;   Gaz.  Hebcl,  1865,  p.  h\o. 


OPERATIONS    OX    THE    MUSCULO-SPIRAL    NERVE.  105 

h3'pertrophied  in  its  lower  part,  and  above,  strangled  (as  if  by  a  liga- 
ture) by  a  point  of  bone  apparently  belonging  to  the  lower  fragment. 
This  point  being  cut  off,  and  a  probe  passed  behind  the  nerve  to  secure 
its  complete  isolation,  the  nerve  was  then  followed  for  i  inch  above 
and  beloAV  the  bony  canal,  so  as  to  ensure  its  liberation,  and,  in  order 
to  obviate  an}^  reproduction  of  bone,  the  periosteum  was  removed  all 
round.  The  nerve  was  not  disturbed  from  its  gutter  for  fear  of  con- 
tusing or  stretching  it.  The  wound  healed  rapidly.  From  the  sixth 
day  the  patient  experienced  some  pricking  sensations  on  the  back  and 
outer  part  of  the  forearm,  and  sensibility  began  to  increase  in  the 
thumb  and  forefinger.  On  the  twentieth  day  he  could  raise  his  hand 
a  little  by  voluntary  efforts,  and  when  he  left  the  hospital  six  months 
and  a  half  after  the  operation,  he  insisted  on  going  back  to  his  work 
in  the  fields. 

A  second  case  of  this  nature  occurred  in  the  practice  of  M.  Trelat, 
and  a  third  has  been  recorded  by  M.  Tillaux.*  The  patient  was  a 
man  of  lift}',  who  had  fractured  the  middle  of  his  humerus  without 
any  lesion  to  the  nerves  at  the  time.  When  the  splints  were  removed 
there  was  complete  paralysis  of  the  extensors.  Four  months  after  the 
accident,  M.  Tillaux  operated  to  free  the  nerve  from  the  pressure  of 
the  callus.  The  trunk  of  the  musculo-spiral  was  easily  discovered  by 
an  incision  made  below  the  fracture  between  the  brachialis  anticus 
and  the  supinator  longus.  The  nerve  was  then  followed  up,  set  free 
from  the  fibro-bony  material  which  surrounded  it,  and  the  bony 
edges  of  the  gutter  were  removed  with  the  chisel.  Three  months  after 
the  operation  the  patient  was  completely  cured. 


CHAPTER    VI. 

OPERATIONS  ON    THE   AXILLA  AND   SHOULDER. 

LIGATURE   OF  AXILLARY  ARTERY  (Figs.  30  and  31). 

Indications. 

1.  \\'ound  of  the  artery .f 

2.  Aneurism  of  the  brachial  high  up.ij; 

*  Trait6  d'Anatomie  topographiqiie,  p.  511. 

f  In  some  wounds  of  tlie  artery,  the  surrounding  parts — e.g.,  veins  and  nerves — may 
be  so  injured  that  the  vitality  of  tlie  limb  is  impaired  beyond  what  ligature  and  nerve- 
suture  can  do,  and  the  advisability  of  amputating  at  the  shoulder-joint  must  be  con- 
sidered. 

X  Dr.  Holt  {Amer.  Journ.  Med.  Sci.,  April,  1882)  nienticms  a  case  (p.  385)  of  aneu- 
rism of  the  right  brachial  at  its  up{>er  third;  ligature  of  the  axillary  in  its  lower 
third;  secondary  hfemorrhage;  ligature  of  the  axillary  artery  in  its  upper  third  ;  cure. 


106  OPERATIONS    OX    THE    UPPER    EXTREMITY. 

More  rarely  still — 

3.  As  a  distal  operation  for  aneurism  of  the  subclavian. 

4.  Very  occasionally,  as  the  old  operation  after  rupture  of  the  axil- 
lary artery  in  shoulder  dislocations  (p.  112). 

5.  Very  occasionally,  as  the  old  operation  for  axillary  aneurism 
(p.  111). 

6.  For  haemorrhage  from  malignant  disease  in  the  axilla. 

These  cases  are  extremely  rare,  but  a  good  instance,  and  one  showing 
the  difficulty  of  meeting  them,  has  lately  been  published  by  Mr. 
Savory  (Med.  Chlr.  Trans.,  \ol.  Ixix.  p.  157).  During  an  attempt  made 
to  remove  a  sarcomatous  growth  from  the  axillary  region,  it  was 
found,  after  division  of  the  pectoral  muscles,  that  the  growth  com- 
pletely invested  the  axillary  vessels  for  8  or  4  inches  in  the  upper 
part  of  their  course.  Though  the  knife  was  not  used  here  at  all,  arte- 
rial blood  began  to  gush  up  from  this  region,  and,  as  no  artery  could 
be  found  even  after  division  of  the  axillary  vein,  two  pressure  forceps 
were  applied  to  the  bleeding  spots  and  left  in  situ,  as  all  attempts  to 
apply  ligatures  were  futile.  '1  he  man  rallied  from  the  operation,  and 
for  just  a  week  went  on  as  well  as  possible.  Then,  on  a  sudden,  vio- 
lent haemorrhage  recurred,  and  death  followed  at  once. 

On  tracing  the  axillary  artery  from  below,  an  irregular  aperture 
was  found  in  the  artery,  just  above  the  lower  border  of  the  tumor, 
and  from  this  point  upwards  the  artery  was  completely  broken  up, 
so  that  for  2  or  3  inches  no  further  trace  of  arterial  wall  could  be 
discovered.  The  boundary  of  the  cavity  beyond,  through  which  the 
blood  must  have  passed,  appeared  to  be  simply  the  substance  of  the 
tumor,  until  at  its  upper  part,  just  below  the  clavicle,  arterial  wall 
was  again  found. 

Operations. — Ligature  of  the  first  and  the  third  parts  of  the  artery 
will  be  first  described,  and  then  the  old  operation. 

i.  Ligature  of  the  First  Part  (Fig.  30).— This  operation  is  very 
rarely  performed  on  the  living  subject.*  Owing  to  the  depth  of  the 
vessel  here,  its  most  important  and  intimate  surroundings,  and  the 
risk  of  secondary  haemorrhage  from  the  vessels  which  lie  so  close  to 
the  knot,  ligature  of  the  third  part  of  the  subclavian  is  preferred  if 
ligature  be  required  for  axillary  aneurism.  On  the  dead  subject  the 
student  should  always  take  the  oportunity  of  tying  the  first  part  of 
the  axillary,  as  it  is  an  excellent  test  of  anatomical  knowledge  and 
practical  skill. 

Line. — From  the  centre  of  the  clavicle  (with  the  arm  drawn  from 
the  side)  to  the  inner  margin  of  the  coraco-brachialis. 

Guide. — The  above  line,  and  the  inner  margin  of  coraco-brachialis 
(P-  109). 

*  See  the  last  note. 


ligature  of  the  axillary  artery.  107 

Relations:  In  Front. 

Skin;  fascife;  fibres  of  platysma.     Supra-clavicular  nerve. 
Pectoralis  major  (with  muscular  branches). 
Costo-coracoid  membrane. 
Cephalic  vein.     Acromio-thoracic  vessels. 

Outside.  ^^.,1,^^,.^  ^.j^,.,,^  Inside. 

Outer  and  inner  cords  first  part.  Axillary  vein, 

of  brachial  plexus. 

Behind. 
First  digitation  of  serratus  magnus. 
First  intercostal  space  and  muscle. 
Posterior  thoracic  nerve. 
Collateral  Circulation. 

(rO  If  the  artery  be  tied  in  its  first  part,  and  the  ligature  be  placed 
above  the  acromio-thoracic,  the  vessels  concerned  svill  be  the  same  as 
those  which  carry  on  the  blood  supply  after  ligature  of  the  third  j^art 
of  the  subclavian  {q.v.). 

(b)  If  the  artery  be  tied  in  its  third  part  and  the  ligature  be  placed 
below  the  circumflex  arteries,  the  anastomosing  vessels  will  be  the 
same  as  after  ligature  of  the  l)rachial  above  the  superior  profunda 
(p.  94). 

(c)  If  the  artery  be  tied  in  its  third  part,  and  the  ligature  be  placed 
between  the  circumflex  and  subscapular  arteries,  the  chief  vessels 
coVicerned  are : 

Above.  Below. 

The  supra-scapular      1  -.i      rn  +    •        •  a 

rr,,  -A  •     r        with     Ihe  posterior  circumnex. 

The  acromio-thoracic  J  ^ 

{d)  If  in  tying  the  third  i^art  of  the  artery  the  ligature  be  placed 

above  the  subscapular,  the  anastomoses  are  more  numerous — viz.,  in 

addition  to  those  just  given  : 

Above.  Below. 

The  supra-scapular        1  .  ,      ^i 

rp,i          \    .  1       >      with     The  subscapular. 

The  posterior  scapular  j  ^ 

Operation. — The  vessel  may  be  secured  in  the  following  ways. 

The  first  two  are  recommended. 

A.  By  a  curved  incision  below  the  clavicle.  This  gives  the  neces- 
sary room,  but  has  the  disadvantage  of  dividing  the  pectoralis  major 
and  its  large  muscular  branches. 

B.  By  an  incision  in  the  interval  between  the  pectoralis  major  and 
deltoid  (Fig.  30).  This  method  scarcely  gives  sufficient  room,  espe- 
cially if  the  parts  are  displaced  by  effused  blood,  etc.,  and  it  is  well 
to  supplement  the  incision  in  the  interval  by   one  partly  detaching 


108  OPERATIOXS    ON    THE    UPPER    EXTREMITY. 

the  pectoralis  from  the  clavicle  (p.  109).  While  this  plan  involves  less 
hsemorrhage  from  the  pectoralis  major,  care  must  be  taken  to  avoid  the 
cephalic  vein  and  acromio-thoracic  branches  which  lie  in  this  interval. 
C.  By  an  incision  in  the  line  of  the  artery — viz.,  one  32-4  inches 
long,  starting  from  just  outside  the  centre  of  the  clavicle  and  passing 
downwards  and  outwards.  This  has  the  disadvantage  of  cutting  the 
muscular  branches  of  the  pectoralis  major,  and  gives  less  space  than 
the  first  two. 

A.  The  limb  being  at  first  abducted,  the  surgeon,  standing  between 
it  and  the  body,  which  is  brought  to  the  edge  of  the  table,  makes  a 
curved  incision,  with  its  convexity  downwards  and  about  h  inch  from 
the  clavicle,  reaching  from  just  outside  the  sterno-clavicular  joint  to 
the  coracoid  process,  the  knife  being  used  lightly  at  the  outer  end  of 
the  incision,  so  as  to  avoid  wounding  the  cephalic  vein  and  branches 
of  the  acromio-thoracic  vessels.  The  clavicular  origin  of  the  pecto- 
ralis major  is  then  divided  in  the  whole  extent  of  the  wound,  and  any 
muscular  branches  which  require  it  tied  or  twisted  at  once.  The 
cellular  tissue  beneath  the  muscle  being  next  explored  with  tip  of 
finger  and  director,  the  upper  border  of  the  pectoralis  minor  is  defined, 
and  this  muscle  drawn  downwards.  The  costo-coracoid  membrane 
must  next  be  most  carefully  torn  through  close  to  the  coracoid  pro- 
cess, which  is  a  good  guide,  by  means  of  a  fine-pointed  steel  director, 
the  cephalic  vein  and  acromio-thoracic  vessels  being  most  scrupulously 
avoided.  The  wound  all  this  time  must  be  kept  dry,  and,  if  needful, 
a  large  laryngeal  mirror  may  be  usefully  employed  in  throwing  light 
into  the  bottom  of  the  deep  wound.  The  pulsation  of  the  artery  being 
felt  for  and  the  sheath  exposed,*  the  vessel  itself  is  to  be  carefully 
cleaned  and  separated  from  the  vein,  which  lies  below  and  in  front, 
and  from  the  brachial  cords,  which  are  above  the  artery.  The  needle 
should  be  passed  from  below  so  as  to  avoid  the  vein.f 

B.  By  an  incision  made  between  the  pectoralis  major  and  deltoid 
(Fig.  30). 

The  limb  and  the  surgeon  being  in  the  same  position  as  in  the 
operation  just  given,  an  incision  is  made  obliquely  downwards  and 
outwards  between  tlie  above  muscles,  commencing  a  little  below  the 
clavicle  opposite  to  the  coracoid  process.  Care  being  taken  to  avoid 
the  cephalic  vein  and  branches  of  the  acromio-thoracic  vessels,  the 
muscles  are  separated,  and,  to  gain  more  room,;{;  a  transverse  incision 
is  made  runnino-  inwards  alono;  the  lower  border  of  the  clavicle,  and 


*  The  parts  may  now  be  advantageously  relaxed  by  adducting  the  arm. 
f  The  patient  must  be  prepared  for  probably   weakened  or  limited  use  of  his    limb 
for  .some  time,  at  least,  after  the  main  arterial  trunk  has  been  ligatured. 

X  This  step  is  advocated  by  Mr  Rivington  {Brit.  Med.  Journ.,  1885,  vol.  i.  p.  1040). 


I.IGATUEE    OF    THE    AXILLARY    ARTERY. 


109 


detaching  as  much  as  is  required  of  the  clavicular  origin  of  the  pecto- 
ralis  major  from  the  bone.  This  flap  can  be  turned  inwards  and 
downwards  without  any  interference  with  the  nerve  supply  of  the 


Fig.  3L 


Fig.  :W.— Part  of  the  clavicular  origin  of  the  pectoralis  major  has  been  turned  inwards  with 
the  flap  of  skin.  The  costo-coracoid  membrane  is  seen  cut  above  and  below  the  artery,  in  the 
latter  case  being  turned  down  over  the  pectoralis  minor. 

The  cephalic  vein  runs  up  along  the  inner  edge  of  the  deltoid  ;  another  vein  lies  on  the  cords 
of  the  brachial  plexus  above  the  artery,  while  some  other  veins  cross  the  upper  part  of  the  wound. 

Fig.  31.— The  lower  incision  shows  ligature  of  the  brachial  in  the  middle  of  the  arm  (p.  95). 
The  artery  is  immediately  internal  to  the  inner  edge  of  the  biceps,  the  median  nerve  having 
crossed  the  vessel  rather  high  up. 

In  the  ligature  of  the  third  part  of  the  axillary,  the  artery,  with  the  median  nerve  on  the  outer 
and  the  ulnar  on  the  inner  side,  lies  just  internal  to  the  coraco-brachialis.  In  both  the  opeia- 
tions  too  much  of  the  nerves  is  shown. 

muscle,  and,  owing  to  its  high  division,  less  haemorrhage  is  met  with 
by  this  method.  The  deltoid  being  strongly  drawn  outAvards  with  a 
retractor,  the  upper  border  of  the  pectoralis  minor  is  defined,  and  the 


110  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

operation  completed  as  in  the  account  already  given,  tlie   parts  being 
relaxed  at  this  stage  by  adduction  of  the  arm. 

ii.  Ligature  of  the  Third  Part  of  the  Axillary  Artery 

(Fig.  31> 

Line. — From  the  centre  of  the  clavicle  with  the  arm  drawn  from 

the  side  to  the  inner  margin  of  the  coraco-brachialis. 

Guide. — The  above  line.     A  line  drawn   from  the  junction  of  the 

middle  and  anterior  thirds  of  the  axilla,  along  the  inner  border  of  the 

coraco-brachialis. 

Relations:  In  Front. 

Skin ;  fascise. 

Pectoralis  major. 

Outside.  Inside. 

Musculo-cutaneous.me-  .    .,,  .  Internal         cutaneous; 

'  Axularv  arterv,  .  ' 

dian.     Inner    border  third  part.  '  ulnar.    Axillary  vein 

of  coraco-brachialis.  or  venee  comites. 

Behind. 

Subscapularis.     Latissimus  dorsi.     Teres  major. 

Circumflex.     Musculo-spiral. 

Operation  (Fig.  31). — This  resembles  somewhat  that  for  ligature 
of  the  brachial  in  the  middle  of  the  arm.  As  with  the  brachial,  so 
with  the  axillary  here ;  though  the  vessel  is  comparatively  superficial, 
it  is  not  an  easy  one  to  hit  off  at  once,  owing  to  the  numerous  sur- 
rounding nerves,  which  may  resemble  the  artery  closely,  especially  if 
blood-stained. 

The  arm  being  extended  from  the  side  and  rotated  slightly  out- 
wards, the  surgeon,  sitting  between  the  limb  and  the  trunk,  makes  an 
incision,  2?  or  3  inches  long,  at  the  junction  of  the  anterior  and  mid- 
dle thirds  of  the  space  along  the  inner  border  of  the  coraco-brachialis 
(Fig.  31).  The  incision  may  be  begun  above  or  below,  as  is  most 
convenient.  Skin  and  fascia3  being  divided,  and  the  point  of  a  direc- 
tor used  more  deeply,  the  axillary  vein  and  the  median  nerve  should 
be  identified,  the  latter  drawn  inwards  and  the  former,  together  with 
the  coraco-brachialis,  outwards.  The  artery  is  then  made  sure  of, 
cleaned,  and  the  needle  passed  from  within  outwards,  the  neighbor- 
hood of  any  large  branch,  such  as  the  subscapular  or  the  circumflex, 
being  avoided,  and  the  needle  being  kept  very  close  to  the  artery. 

iii.  Old  Operation  of  Ligature  of  Axillary  Artery  for 
Some  Cases  of  Axillary  Aneurism  and  Injured  Axillary 
Artery. — Tliis  method  may  be  made  use  of  in  the  following  in- 
stances : 

1.  When  pressure  has  failed  in  the  above  cases. 

2.  Where  pressure  is  unsuitable  owing  to  the  rapid  increase,  and 


LIGATURE   OF    THE    AXILLARY    ARTERY.  Ill 

large  size,  of  the  aneurism  ;  the  condition  of  the  parts  over  it ;  or  the 
inability  of  the  patient  to  hear  pain. 

3.  Where,  owing  to  the  displacement  of  the  clavicle,  ligature  of  the 
subclavian  is  not  likely  to  be  practicable,  or  where  the  condition  of 
the  coverings  of  the  aneurism  is  such  that  this  step,  even  if  carried 
out,  will  not  avert  suppuration,  sloughing,  etc. 

Prof.  Syme  {Observations  in  Clin.  Surgery,  p.  140  et  seq.),  holding  that 
the  old  method  would  certainly  remedy  cases  not  amenable  to  liga- 
ture of  the  subclavian,  and  that  even  in  cases  where  the  latter  is  prac- 
ticable the  former  might  be  preferable,  made  use  of  it  in  three  cases, 
the  patients  being  aged  fifty,  forty -seven,  and  about  fifty  respectively. 
In  the  first  case,  the  skin  in  the  neighborhood  of  the  shoulder-joint 
was  dusky  red  and  vesicating,  and  the  patient  beginning  to  wander 
in  his  mind.  In  the  third,  after  the  operation,  delirium  tremens  set 
in,  with  excessive  suppuration  and  sloughing  of  the  tissues  of  the  limb. 
All  three  recovered. 

The  following  is  an  account  of  the  operation  in  Prof.  Syme's  words 
(toe.  supra  cit.  p.  148) :  '"  I  made  an  incision  along  the  outer  edge  of 
the  sterno-mastoid  through  the  platysma  myoides  and  fascia  of  the 
neck,  so  as  to  allow  a  finger  to  be  pushed  down  to  the  situation  where 
the  subclavian  lies  upon  the  first  rib.  I  then  opened  the  tumor,* 
when  a  tremendous  gush  of  blood  showed  that  the  artery  was  not  ef- 
fectually compressed ;  but  while  I  plugged  the  aperture  with  my  hand, 
Mr.  Lister,  who  assisted  me,  by  a  slight  movement  of  his  finger,  which 
had  been  thrust  deeply  under  the  upper  edge  of  the  tumor  and 
through  the  clots  contained  in  it,  at  length  succeeded  in  getting  com- 
mand of  the  vessel.  I  then  laid  the  cavity  freely  open,  and  with  both 
hands  scooped  out  nearly  7  pounds  of  coagulated  blood.  The  axillary 
artery  appeared  to  have  been  torn  across,  and,  as  the  lower  orifice 
still  bled  freely,  I  tied  it  in  the  first  instance,  next  cut  through  the 
lesser  pectoral  muscle  close  up  to  the  clavicle,  and,  holding  the  upper 
end  of  tlie  vessel  between  my  finger  and  thumb,  passed  an  aneurism 
needle  so  as  to  apply  a  ligature  about  i  inch  above  the  orifice.  The 
extreme  elevation  of  the  clavicle,  which  rendered  the  artery  so  inac- 
cessible from  above,  of  course  facilitated  this  procedure  from  below. 
Everything  went  on  favorably  afterwards." 

Sir  J.  Paget  and  Mr.  Callender  (St.  B(irtholomcw\s  Hasp.  Reps.,  vol. 
ii.)  made  a  H-shaped  incision,  cutting  parallel  with  the  lower  margin 
of  the  pectoralis  major,  and  a  second  at  right  angles  to  the  first 
straight  up  through  the  whole  width  of  the  pectoralis  major. 

A  short  space  may  be  allotted  here  to  that  most  im})ortant  accident 


*  In  one  of  liis  cases,  wliile  laying  open  the  cavity,  Prof.  Syme  had  to  avoid  tlie 
radial  artery,  which  ran  over  the  siii-face  of  the  sac. 


112  OPERATIOXS    ON    THE    UPPER    EXTREMITY. 

which  has  happened  to  so  many  surgeons — viz.,  rupture  of  the  ax- 
illary artery  while  dislocations  of  the  shoulder  are  being  reduced.  Of 
late  years  the  great  fatality  which  the  old  operation  has  met  with  here 
has  been  pointed  out.  Dr.  Stimson  (Ann.  of  Surg.,  Nov.,  1885)  draws 
the  following  conclusions  from  forty-four  cases:  "Conservative  treat- 
ment— viz.,  complete  rest  with  direct  pressure — may  properly  be  tried 
at  first,  especially  if  the  tumor  is  small,  recent,  and  not  increasing, 
but  should  not  be  prolonged  if  the  symptoms  do  not  promptly  yield  ; 
and,  secondly,  in  case  of  resort  to  operation,  ligature  of  the  subclavian 
or  disarticulation  at  the  shoulder  is  to  be  preferred  to  incision  of  the 
sac  and  double  ligature  of  the  artery."  Of  seven  cases  of  double  liga- 
ture of  the  artery,  all  were  fatal.  Of  fourteen  of  ligature  of  the  sub- 
clavian, five  recovered.  Without  operation,  thirteen  died,  six  re- 
covered. Of  four  cases  of  amputation  at  the  shoulder,  only  one 
recovered.  Repeated  puncture  is  always  fatal.  Korte,  of  Berlin 
(Arch.  f.  Min.  Chir.,  Bd.  xxvii.  Hft.  3,  quoted  by  Dr.  Stimson),  is  of 
opinion  that  in  many  cases  the  injury  to  the  artery  is  caused  at  the 
time  of  the  accident,  but  haemorrhage  does  not  come  on  till  after  re- 
duction is  brought  about,  as  the  vessel  is  compressed  by  the  head  of 
the  bone.  As  to  the  exact  cause  of  the  injury  to  the  vessel  when  it 
takes  place  at  the  time  of  the  reduction,  it  is  probable  that  some  special 
condition  exists  to  account  for  it,  as  so  many  old  dislocations  are  re- 
duced with  much  force,  used  with  impunity— g.^^.,  atheroma ;  adhe- 
sion of  the  artery  to  the  head  of  the  bone;  too  great  or  misapplied 
force  in  reduction,  viz.,  use  of  the  boot,  in  elevation;  projection  of  a 
fragment  or  a  spicule  of  bone.  It  is  usually  the  axillary  artery,  or 
one  of  its  branches,  which  gives  way ;  much  more  rarely  (four  out  of 
forty-four  cases),  the  axillary  vein. 

The  following  remarks  with  which  Mr.  Holmes*  (Hunterian  Lect- 
ures) summed  up  the  treatment  of  axillary  aneurism  are  well  worthy 
of  thoughtful  perusal : 

"  1.  There  are  a  great  number  of  these  aneurisms,  both  traumatic  and 
spontaneous,  which  are  amenable  to  gradual  intermitting  pressure 
when  carefully  applied  to  the  artery  above  the  tumor. 

"  2.  That  in  cases  where  this  is  not  possible,  from  the  ))ain  Avhich 
the  person  experiences  on  pressure,  the  application  of  rapid  total  com- 
pression under  anaesthesia  may  eff'ect  a  cure. 

"  3.  That  the  ligature  of  the  subclavian  is  so  dangerous  an  operation, 
both  from  its  own  risks  and  the  proximity  of  the  sac,  that  it  ought  to 
be  restricted  to  cases  where  pressure  has  failed,  and  to  those  in  which, 
from  the  size  and  rapid  growth  of  the  axillary  swelling  the  surgeon 
thinks  pressure  unadvisable. 

■'  *  Lancet,  September  27,  1873. 


AMPUTATION    AT    THE    SHOULDER- JOINT.  113 

"4.  That  the  old  operation  is  to  be  preferred  to  ligature  of  the  sub- 
clavian in  cases  of  ruptured  arter}^  and  that  it  ma}^  be  practiced  in 
cases  where,  from  the  elevation  of  the  shoulder  or  from  the  extent  of 
the  swelling,  the  surgeon  would  find  it  difficult  to  tie  the  subclavian, 
or  fears,  in  doing  so,  to  injure  the  sac,  but  that  the  anatomical  rela- 
tions of  axillary  aneurisms  render  this  a  peculiarly  hazardous  pro- 
ceeding, and  the  surgeon  should  always  be  prepared  to  amputate  if 
necessary. 

"5.  That  in  very  large  axillary  aneurisms,  if  any  treatment  be 
adopted,  the  arm  should  be  amputated  at  the  shoulder-joint'''  after 
ligature  of  the  subclavian." 

AMPUTATION  AT  THE   SHOULDER-JOINT. 

Indications. 

i.  Compound  comminuted  fractures — e.  g.,  raihvay  and  machinery 
accidents. 

ii.  Gunshot  injuries. — Amputation  here  is  divided  by  Dr.  Otisr  int^o 
— (1)  Primary,  or  before  the  third  day ;  (2)  Intermediary,  or  cases  in 
which  the  operation  was  performed  between  the  third  and  the  thirtieth 
days  ;  (S)  Secondary,  in  which  the  operation  was  performed  later  than 
the  thirtieth  day. 

(1)  Primary. — The  mortality  here  was  24  per  cent.  The  indica- 
tions for  amputations  so  soon  after  the  injury  are  chiefly — (a)  A  limb 
torn  off  partially,  but  too  high  to  admit  of  any  other  amputation;  (b) 
Severe  comminuted  fracture  of  the  upper  end  of  the  humerus,  with 
extensive  injury  to  the  vessels  and  nerves;  (c)  Such  a  fracture  high 
up,  with  severe  splintering  extending  down  below  the  insertions  of  the 
pectoralis  major  and  the  latissimus  dorsi. 

(2)  Intermediary. — The  mortality  here,  45  per  cent.,  was  nearly 
double  that  of  the  primary.  This  seems  to  have  been  brought  about 
largely  by  the  fact  that  the  operation  was  now  performed  through 
soft  parts,  the  seat,  at  this  time,  of  unhealthy  inflammation,  and  thus 
prone  to  lead  to  secondary  haemorrhage,  pysemia,  sloughing,  etc. 

(3)  Secondary. — The  causes  for  this  deferred  operation  were  chiefly 
haemorrhage,  gangrene,  profuse  suppuration,  hopeless  disease  of  the 
humerus,  sometimes  with  consecutive  implication  of  the  joint,  chronic 
osteo-myelitis,  or  necrosis  of  the  entire  humerus.  The  mortalitv  was 
28  per  cent. 

From  the  above  it  is  evident  that  the  necessary  examination  should 
be  made,  and  the  operation  performed,  as  soon  after  the  injury  as 
possible  consistent  with  the  state  of  the  patient,  the  difference  between 

*  P.  110. 

« 
t  Jfe<l.  u)id  Surg.  Hist,  of  the  War  of  the  Rebellion,  pt.  ii.  p.  613  et  seq. 

8 


114  OPEllATIOXS    ON    THE    UPPER    EXTREMITY. 

operating  in  sound  and  diseased  parts,  and  the  neighborhood  of  the 
joint  to  the  chest,  if  a  septic  condition  of  the  wound  sets  in,  being 
borne  in  mind. 

iii.  New  growths. — If  these  involve  the  scapula  or  its  processes, 
amputation  at  the  shoulder-joint  should  be  combined  with  removal  of 
the  scapula  (p.  144).'^^ 

iv.  Disease  of  the  shoulder-joint  unsuited  for,  or  persisting  after 
failure  of  excision. 

V.  For  osteo-myelitis  and  necrosis  of  humerus  resisting  other  treat- 
ment, or  complicated  with  early  blood-poisoning. 

vi.  For  rapidly  spreading  gangrene  or  gangrenous  cellulitis  with 
threatening  septicaemia. 

Mr.  Heath  (Clin.  Soc.  Trans.,  vol.  xiv.  p.  114)  has  recorded  such 
a  case  in  which  this  amputation  was  needed  to  save  life.  A  nurse 
had  pricked  her  finger  deeply  with  a  pin  hidden  in  some  of  the 
clothes  of  a  lady  who  had  died  of  virulent  puerperal  septicaemia;  gan- 
grenous cellulitis  rapidly  set  in,  and  extended  in  spite  of  incisions  ;  on 
the  sixth  day  the  gangrene  appeared  to  be  arrested  in  the  forearm, 
though  there  was  a  blush  of  advancing  mischief  up  the  arm.  In  the 
afternoon  of  the  same  day  sudden  extension  took  place,  and  Mr. 
Heath  removed  the  arm  at  the  shoulder-joint,  the  patient  ultimately 
making  a  good  recovery. 

The  operation  chosen  was  by  outer  and  inner  flaps,  the  former 
giving  a  fairly  healthy  flap  of  deltoid,  the  latter  having  to  be  cut  very 
short  owing  to  the  infiltration  of  the  axilla.  The  dressings  became 
offensive,  but  the  stump  healed  well. 

vii.  Amputation  at  the  shoulder-joint  may  be  called  for  in  the  fol- 
lowing cases  of  aneurism  : 

A.  In  some  cases  of  subclavian  aneurism  where  other  means  have 
failed  or  are  impracticable ;  where  the  aneurism  is  rapidly  increasing ; 
where  the  pain  is  constant  and  agonizing;  and  where  the  limb  is 
threatening  to  become  gangrenous.  While  the  principle  of  this  opera- 
tion appears  to  be  physiologically  sound — i.e.,  to  enable  distal  ligature 
to  be  performed  on  the  face  of  the  stump,  and  that,  by  removal  of  the 
limb,  the  amount  of  blood  passing  through  the  aneurism  may  be 
diminished— the  results  hitherto  have  not  been  very  successful.  Thus, 
in  Prof.  Spence'st  case,  a  man  aged  thirty-three,  with  a  subclavain 
aneurism,  probably  encroaching  on  the  second,  if  not  the  first,  part  of 
the  artery,  with  excruciating  pain  and  threatening  gangrene,  amputa- 
tion at  the  shoulder-joint  was  followed  by  diminution  in  the  pulsation 

*  Tlie  question  of  tlie  possibility  of  saving  tiie  limb  and  removing  the  growth  by 
excision  of  the  head  of  the  humerus  is  considered  at  p.  128. 
t  3Ied.  Chir.  Trans.,  vol.  Iii.  p.  806. 


AMPUTATION    AT    THE    SHOrLDER- JOINT.  115 

and  size  of  the  sac,  but  with  little  formation  of  coagula.  Death  took 
place  four  years  afterwards,  probably  from  extension  of  the  aneurism 
to  the  innominate  and  aorta.  In  this  case  the  operation,  though  it 
had  but  little  effect  in  consolidating  the  sac,  undoubtedly  prolonged 
life,  as  gangrene  was  threatening,  and  the  second  part  of  the  artery 
was  almost  certainly  affected,  thus  rendering  the  case  a  most  unfavor- 
able one.  In  Mr.  Holden's*  case  the  patient  was  almost  in  extremis,  and 
the  sac  gave  way.  In  Mr.  H.  Smith'sf  case  an  intra-thoracic  portion 
of  the  aneurism  also  ruptured,  there  being  no  evidence  as  to  benefit 
or  otherwise.  In  Mr.  Heath'sJ  case  (the  aneurism  being  perhaps 
traumatic  in  origin,  and  of  the  false  circumscribed  kind)  the  effect  on 
the  aneurism  was  so  transient  as  to  be  practically  nil.  Two  months 
after  the  amputation,  as  the  aneurism  continued  to  increase  in  size, 
Mr.  Heath  introduced  into  the  sac  three  pairs  of  fine  sewing  needles, 
making  each  pair  cross  within  the  sac.  Considerable  clotting  took 
place  around  the  needles,  which  were  withdrawn  on  the  fifth  day. 
The  aneurism  gradually  became  solid,  but  the  patient  sank  soon 
after  from  bronchitis.  Mr.  Heath  concluded  that  amputation  at  the 
shoulder-joint  for  aneurism  is  not  a  satisfactory  proceeding,  but  the 
majority  of  surgeons  present  were  in  favor  of  further  trials  of  this 
mode  of  treatment  if  it  could  be  resorted  to  early. 

B.  With  the  same  objects  in  view,  amputation  at  the  shoulder-joint 
may  be  required  in  some  cases  of  axillary  aneurism  complicated  with 
extension  of  the  sac  upwards,  much  elevation  of  the  shoulder,  condi- 
tions which  may  render  compression  or  ligature  of  the  subclavian  im- 
possible, removal  of  the  limb  being  additionally  called  for  if  agonizing 
pain  or  threatening  gangrene  is  present. 

Prof.  Syme§  briefly  alludes  to  two  such  successful  cases,  in  one  of 
which  gangrene  was  threatening :  "  In  a  case  of  axillary  aneurism  in 
a  gentleman  of  about  fifty-two  years  of  age,  where  ligature  was  pre- 
vented by  intense  inflammation  of  the  arm,  rapidly  running  on  to 
gangrene,  I  performed  amputation  at  the  shoulder-joint,  cutting 
through  the  sloughy  sides  of  the  aneurism  and  tying  the  artery  where 
it  lay  within  the  sac." 

C.  In  some  cases  of  inflamed  axillary  aneurism  threatening  sup- 
puration, Mr.  Erichsen||  points  out  that  the  question  of  this  amputa- 
tion may  arise.     As  the  old  operation  of  opening  the  sac,  turning  out 

*  St.  Barthol.  Hasp.  Reports,  vol.  xiii. 

t  Quoted  by  Mr.  Heath,  loc.  infra  cit. 

X  In  a  paper  brought  before  the  Metlico-Chirurgical  Society  (Trans.,  vol.  Ixiii.  p. 
65).  For  the  discussion  on  this,  see  Lancet,  1880,  vol.  i.  p.  169;  Brit.  Med.  Journ  ,. 
1880,  vol.  i.  p.  205. 

?   Hfed.  Chir.  Trans.,  vol.  xliii.  p.  139. 

II  Surg.,  vol.  ii.  p.  217. 


116  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

the  clots,  and  securing  the  vessel  above  and  below  is  impossible,  owing 
to  the  fact  that  the  coats  of  the  vessel,  now  softened,  will  not  hold  a 
ligature,  two  courses  only  are  open  to  the  surgeon — viz.-,  ligature  of  the 
third  part  of  the  subclavian  or  amputation  at  the  shoulder-joint. 
While  the  former  may  be  followed  when  the  aneurism  is  moderate  in 
size  and  when  there  is  no  evidence  of  threatening  gangrene,  amputa- 
tion must  be  resorted  to  when  less  favorable  conditions  are  present. 

If  haemorrhage  occur  from  an  inflamed  axillary  aneurism  which 
has  ruptured  after  the  subclavian  has  been  already  tied,  Mr.  Erichsen, 
of  the  two  courses  now  open — viz.,  either  to  open  the  sac  and  try  and 
include  the  bleeding  spot  between  two  ligatures,  or  to  amputate  at  the 
shoulder-joint— strongl}^  advises  the  latter. 

The  coats  of  the  artery  "  in  the  immediate  vicinity  of  the  sac  could 
not,  in  accordance  with  what  we  know  to  be  almost  universally  the 
case  in  spontaneous  aneurisms  of  large  size  or  old  standing,  be  ex- 
pected to  be  in  anything  like  a  sound,  firm  state,  and  would  almost 
certainly  give  way  under  pressure  of  the  noose ;  or  the  vessel  might 
have  undergone  fusiform  dilatation,  as  is  common  in  this  situation, 
before  giving  rise  to  the  circumscribed  false  aneurism,  in  which  case 
it  would  be  impossible  to  surround  it  by  a  ligature  ;  or,  again,  the 
subscapular  or  circumflex  arteries  might  arise  directly  from,  and  pour 
their  recurrent  blood  into,  the  sac  or  dilated  artery,  and,  as  they  would 
lie  in  the  midst  of  inflamed  and  sloughing  tissues,  no  attempt  at  in- 
cluding them  in  a  ligature  could  be  successfully  made.  In  such  cir- 
cumstances as  these  the  danger  of  the  patient  would  be  considerably 
increased  by  the  irritation  and  inflammation  that  would  be  occasioned 
by  laying  open  and  searching  for  the  bleeding  vessel  in  the  sac  of  an 
inflamed,  suppurating,  and  sloughing  aneurism,  and  much  valuable 
time  would  be  lost  in  what  must  be  a  fruitless  operation,  at  the  close 
of  which  it  would,  in  all  probability,  become  necessary  to  have  re- 
course to  disarticulation  at  the  shoulder-joint,  and  thus  to  remove  the 
whole  disease  at  once." 

D.  In  the  words  of  the  same  writer,*  "there  is  another  form  of 
axillary  aneurism  that  requires  immediate  amputation  at  the  shoulder- 
joint,  whether  the  subclavian  artery  have  previously  been  ligatured  or 
not;  it  is  the  case  of  diffuse  aneurism  of  the  arm-pit,  with  threatened 
•or  actual  gangrene  of  the  limb." 

Different  Methods. — Of  the  thirty-six  different  methods  which 
have  been  enumerated,  most  will  be  found  to  differ  in  some  unimpor- 
tant detail.  Five  methods  will  be  described  here,  which  will  be  found 
sufficient,  if  modified  when  needful,  for  all  cases.  The  circumstances 
under  which  this  amputation  is  performed  do  not  admit  of  any  one 

*  Loc.  supra  cit.,  p.  21 S. 


A.MPUTATION    AT    THE   SHOULDER-JOINT.  117 

definite  method  being  followed.  Thus,  after  a  railway  accident  or 
gunshot  injury,  the  soft  parts  will  be  destroyed  on  at  least  one  sur- 
face. In  amputating  for  malignant  disease,  skin  flaps  must  be  made 
use  of,  transfixion  being  usually  inadmissible,  as  the  muscles  should 
be  cut  as  short  and  as  close  as  possible  to  their  upper  attachments,  to 
minimize  the  risk  of  extension  and  recurrence.  Instead  of  remember- 
ing the  length  and  size  of  differently  named  flaps,  the  surgeon  will 
have  to  be  familiar  with  the  anatomy  of  the  parts,  the  position  of  the 
vessels,  and  the  best  means  of  meeting  haimorrhage. 

The  joint  is  so  well  covered  that  sufficient  flaps  can*  nearly  always 
be  provided,  while  the  blood  supply  is  so  abundant  that  sloughing 
very  rarely  occurs,  and  even  if  it  do  so,  from  the  results  of  injury  or 
hospital  gangrene,  the  tissues  of  the  chest  will  come  forward  suflici- 
ently  to  close  the  wound.  The  fact  that  the  cavity  of  the  axilla  gives 
good  drainage  below  is  of  much  importance. 

The  following  methods  will  be  described  here  :  in  the  first  two,  skin 
flaps  are  made;  in  the  others  (save  in  the  Furneaux- Jordan  method), 
transfixion  is  made  use  of,  in  part  at  least. 

i.  By  lateral  skin  flaps.     The  oval,  or  en  raquette  methods. 

ii.  Spence's  method. 

iii.  Superior  and  inferior  flaps. 

iv.  Superior  or  deltoid  flap. 

V.  Anterior  and  posterior  flaps. 

vi.  Furneaux-Jordan  method.  > 

Means  of  arresting  Hsemorrhage  in  Amputation  at  the 
Shoulder-joint. — These  are  mainly  two  : 

1.  Pressure  on  the  SubclaviAxN. — I  am  of  opinion  that  the  more 
the  surgeon  trusts  to  this  plan  solely,  the  more  often  will  he  have 
cause  to  regret  it.  Pressure,  however  well  applied  at  the  first  with  the 
thumb,  aided  by  a  padded  ke}^  or  a  weight,  is  too  often  rendered  un- 
certain by  the  necessary  changes  in  position  of  the  limb  during  the 
operation,  or  by  the  pressure  of  assistants,  a  violent  gush  of  blood  at 
the  last  showing  to  the  surgeon  that  his  confidence  in  the  artery  being 
secured  is  misplaced.  Furthermore,  an  assistant  so  used  is  neces- 
sarily much  in  the  way  of  the  others  aiding  the  surgeon.  For  the 
above  reasons  I  much  prefer  trusting  to  one  or  other  of  the  two  next 
given. 

2.  Compression  of  the  Inferior  or  Anterior  Flap,  and  so  of  the 
Vessels  before  they  are  cut  (p.  123,  Figs.  35,  36). 

3.  Ligaturing  or  twisting  the  Vessels  on  the  Inner  Aspect  of 
the  Limb  before  they  are  cut  (p.  119,  Fig.  33). 

*  In  some  cases  of  gunshot  injury,  it  is  necessary  to  get  the  chief  flap  from  the 
axillary  region,  and  to  bring  this  np  and  unite  it  to  the  cut  margin  of  skin  over  the 
acromion. 


118 


OPERATIONS    ON    THE    UPPER    EXTREMITY, 


4.  Securing  the  Vessels  lower  down,  in  the  Furneaux-Jordan 
Method  (p.  125). 

5.  Use  of  an  India-Rubber  Band. — This  is  applied  after  the  same 
method  as  that  fully  given  in  amputation  at  the  hip-joint.  In  my 
opinion,  it  is  unreliable,  especially  in  those  cases  of  accident  in  which, 
the  limb  being  mutilated  high  up,  this  operation  is  chiefly  required. 
For  in  these  the  band,  being  applied  under  the  axilla  and  across  the 
body,  slips  up  as  soon  as  the  head  is  disarticulated,  allowing  of 
bleeding  from  the  vessels,  and  coming,  itself,  most  inconveniently  into 
the  way  of  the  operator. 

i.  Lateral  Flaps— Oval— En  Raquette  (Figs.  32  and  33).— 
The  method  of  lateral  flaps,  or  the  above  modifications  of  it,  are  those 
which  the  student  is  especially  recommended  to  practice.     The  fol- 

FiG.  32. 


lowing  are  the  advantages  :  («)  Cutting  from  without  inwards,  and  by 
lateral  flaps,  the  surgeon  can  leave  the  internal  one  to  the  last,  expose 
the  vessels  by  cutting  down  upon  them,  and  secure  them  before  going 
farther.  (/5)  One  flap  can  be  cut  long  and  the  other  short,  according 
to  the  soft  parts  available.  (7)  Part  of  the  incisions  in  this  method 
may  be  made  use  of  to  explore  the  condition  of  the  shoulder-joint  in 
cases  where  the  surgeon  is  in  doubt  whether  excision  or  amputation 
will  be  the  wiser  course  ;  and  again,  this  method  is  easily  employed 
after  failure  of  excision  by  an  extension  of  the  incision  of  the  above 
operation. 

The  methods  of  arresting  ha?morrhage  are  given  at  p.  117.  The 
patient  being  propped  up  sufticiently.  brought  to  the  edge  of  the  table, 
and  rolled  over  to  the  opposite  side,  the  surgeon,  standing  outside  the 


AMPUTATION    AT    THE    SHOULDEK-JOIN'J'. 


]19 


abducted*  limb  on  the  right  side,  and  inside  it  on  the  left,  and  havino- 
marked  with  his  left  forefinger  and  thumb  a  point  just  below  and  out- 
side the  coracoid  process,  and  a  corresponding  point  behind  in  the 
mid-axilla  (Fig.  32),  then  reaches  over,  and,  entering  the  knife  in  the 
axilla,  close  to  the  thumb,  cuts  an  oval  flap,  about  4  inches  long,  con- 
sisting of  skin  and  fasciae,  from  the  outer  side  of  the  limb,  and  ending 
close  to  his  thumb.  Without  removing  the  knife,  the  surgeon  next 
marks  out  a  similar  flap  on  the  inner  side,  cutting  from  above  down- 
wards, commencing  just  below  the  finger,  and  ending  where  the  outer 
flap  began  in  the  mid-axilla.  The  assistant  in  charge  of  the  limb  aids 
the  above  by  rotating  the  limb  into  convenient  position.     The  flaps 


Fig.  33. 


Ficf.  34. 


wiiA 


Fig.  33. — Amputation  at  the  shoulder-joint  by  lateral  flaps.    These  are  turned  aside  while  the 
axillary  artery  is  secured  by  torsion  before  disarticulation  is  completed. 
Fig.  34. — Amputation  at  the  shoulder-joint  by  Spence's  method.    (Stimson.) 


are  then  dissected  up  and  held  out  of  the  way.  The  vessels  are  next 
exposed,  separated  from  the  surrounding  nerves,  and  secured,  either 
by  applying  two  pairs  of  torsion-forceps  (Fig.  33),  dividing  the  vessel 
between  them  and  twisting  both  ends,  or  by  passing  an  aneurism 
needle,  loaded  with  carbolized  silk  or  chromic  gut,  under  the  artery, 
and  thus  securing  it  with  a  ligature.  The  limb  being  then  carried 
across  the  chest,  the  outer  part  of  the  capsule  is  freely  opened  by 
cutting  on  the  head  of  the  bone  and  the  muscles  attached  to  the  great 

*  Three  assistants  are  required  in  an  amputation  at  the  shoulder-joint — (1)  To 
manipulate  the  limb ;  (2)  To  grasp  the  artery  in  the  inner  or  inferior  flap,  if  desired  ; 
(3)  To  be  ready  with  sponges  or  instruments.  If  it  be  desired  to  have  the  subclavian 
controlled,  this  must  be  done  by  No.  3,  p.  117.  If  short-handed,  the  surgeon  will 
manipulate  the  limb  himself. 


120  OPERATIONS    OX    THE    UPPER    EXTREMITY. 

tuberosity  thoroughly  severed.  The  limb  is  next  rotated  outwards, 
and  the  subscapularis  tendon  severed  ;  the  biceps  tendon  being  cut 
and  the  capsule  freely  opened,  the  joint  is  well  opened  on  the  inner 
side.  The  head  being  then  dislocated,*  by  the  assistant  pressing  the 
elbow  forwards  and  against  the  side,  the  knife  is  passed  from  the 
outer  side  behind  the  dislocated  head,  and,  being  kept  close  to  the 
inner  side  of  the  bone,  is  brought  out  through  the  structures  on  the 
inner  aspect  of  the  arm,  care  being  taken,  as  the  knife  cuts  its  way  out, 
that  it  does  so  below  the  point  where  the  large  vessels  have  been 
secured. 

ii.  Spence's  Method  (Fig.  34).— This  modification  of  the  oval 
method  is  especially  suited  to  cases  of  failed  excision,t  or  to  cases  of 
injury — e.g.^  gunshot — where  the  surgeon  has  to  cut  into  and  explore 
the  condition  of  the  joint  before  deciding  on  excision  or  amputation. 
By  its  means  an  excision  can  readily  be  converted  into  a  disarticu- 
lation, if  this  step  is  found  needful. 

Other  advantages,  but  less  important  ones,  are  : 

1.  The  posterior  circumflex  artery  is  not  divided,  except  in  its  small 
terminal  branches  in  front,  whereas,  both  in  the  large  deltoid  flap  and 
the  double  flap  methods,  the  trunk  of  the  vessel  is  divided  in  the 
early  steps  of  the  operation,  and,  retracting,  often  gives  rise  to  embar- 
rassing hsemorrhage. 

2.  The  great  ease  witli  which  disarticulation  can  be  accomplished. 

3.  The  better  form  and  greater  fulness  of  the  stump.  Prof.  Spence 
points  out  that,  however  excellent  are  the  results  soon  after  other  am- 
putations at  the  shoulder-joint,  some  time  later  the  shape  of  the  stump 
is  much  altered,  not  merely  from  the  atrophy  common  to  all  stumps, 
Ijut  from  retraction  of  the' muscular  elements  of  the  flaps,  the  pecto- 
ralis  major  retracting  towards  the  sternum  and  the  latissimus  dorsi 
and  teres  major  towards  the  spine  and  scapula.  By  this  tendency  to 
separation,  a  deep,  ugly  hollow  results  under  the  acromion. 

The  operation  is  thus  described  in  Prof.  Spence's  words  :;|:  "  Sup- 
posing the  right  arm  to  be  the  subject  of  amputation.  The  arm  being 
slightly  abducted,  and  the  head  of  the  humerus  rotated  outwards  if 
possible,  with  a  broad  strong  bistoury  I  begin  by  cutting  down  upon 
the  head  of  the  humerus,  immediately  external  to  the  coracoid  pro- 

*  in  any  case  where  tlie  leverage  of  tlie  Iiiimeriis  is  wanting,  owing  to  tiiis  bone 
being  broken  high  up,  the  use  of  lion-forceps  will  facilitate  disarticulation  ;  or  the  sur- 
geon will  follow  the  expedient  of  Prof.  Synie,  quoted  by  Sir  J.  Lister  {Syst.  of  Surg., 
vol.  iii.  p.  71 2\  and  introduce  his  finger  into  a  wound  in  the  capsule,  for  the  purpose 
of  drawing  down  the  head  of  the  bone,  so  as  to  gain  access  to  its  attachments. 

f  At  the  present  day,  in  cases  of  failed  excision,  the  surgeon  will  often  prefer  to 
make  use  of  the  modification  of  the  Fin-neaux- Jordan  method,  p.  125. 

X  Lancet,  1867,  vol.  i.  p.  143;  and  Led.  on  Surg.,  vol.  ii.  p.  6C2. 


AMPUTATIOX    AT    THE   SHOULDEE-JOINT.  121 

cess,  and  carry  the  incision  down,  through  the  clavicular  fibres  of  the 
deltoid  and  pectoralis  major,  till  I  reach  the  humeral  attachment  of 
the  latter  muscle,  which  I  divide.  I  then,  with  a  gentle  curve,  carry 
the  incision  across  and  fairly  through  the  lower  fibres  of  the  deltoid 
towards  the  posterior  border  of  the  axilla,  unless  the  textures  be  much 
torn.  I  next  mark  out  the  line  of  the  lower  part  of  the  inner  section 
by  carrying  an  incision,  through  the  skin  and  fat  only,  from  the  point 
where  my  straight  incision  terminated,  across  the  inside  of  the  arm,  to 
meet  the  incision  at  the  outer  part.  This  insures  accuracy  in  the  line 
of  union,  but  is  not  essential.  If  the  fibres  of  the  deltoid  have  been 
thoroughly  divided  in  the  line  of  incision,  the  flap  so  marked  out  can 
be  easily  separated  (by  the  point  of  the  finger,  without  further  use  of 
the  knife)  from  the  bone  and  joint,  together  with  the  trunk  of  the  pos- 
terior circumflex,  which  enters  its  deep  surface,  and  drawn  upwards 
and  backwards,  so  as  to  expose  the  head  and  tuberosities.  The  ten- 
dinous insertions  of  the  capsular  muscles,  the  long  head  of  the  biceps, 
and  the  capsule  are  next  divided  by  cutting  directly  on  the  tuberosities 
and  head  of  the  bone,  and  the  broad  subscapular  tendon  especially, 
being  very  fully  exposed  by  the  incision,  can  be  much  more  easih^  and 
completely  divided  than  in  the  double  flap  method.  By  keeping  the 
large  outer  flap  out  of  the  way  by  a  broad  copper  spatula  or  the  finger 
of  an  assistant,  and  taking  care  to  keep  the  edge  of  the  knife  close  to 
the  bone,  as  in  excision,  the  trunk  of  the  posterior  circumflex  is  pro- 
tected. Disarticulation  is  then  accomplished,  and  the  limb  removed 
by  dividing  the  remaining  soft  parts  on  the  axillary  aspect.  The  only 
vessel  which  bleeds  is  the  anterior  circumflex,  divided  in  the  first  in- 
cision, and  here,  if  necessary,  a  pair  of  catch-forceps  can  be  placed  on 
it  at  once.  In  regard  to  the  axillary  vessels,  they  can  either  be  com- 
pressed by  an  assistant  before  completing  the  division  of  the  soft  parts 
on  the  axillary  aspect,  or,  as  I  often  do  in  cases  where  it  is  wished  to 
avoid  all  risk,  by  a  few  touches  of  the  bistoury  the  vessel  can  be  ex- 
posed, and  can  then  be  tied  and  divided  between  two  ligatures,  so  as 
to  allow  it  to  retract  before  dividing  the  other  textures."* 

Surgeon-Major  Porter,  in  his  useful  Surgeon^s  Pocket-book,  i).  185,  thus 
describes  a  very  similar  operation  which  he  accredits  to  Hamilton,  of 
the  TJ.  S.  Army :  "  The  arm  lying  nearly  against  the  side  of  the  body, 
with  a  large  bistoury  an  incision  is  commenced  at  the  middle  point  of 
the  extremity  of  the  acromion  process,  or  two  or  three  lines  above  this 
pointjt  and  carried    perpendicularly  downward  I2  inch,  the   knife 

*  Where  the  limb  is  very  muscular,  Prof.  Spence  recommended  to  raise  the  skin 
and  fat  from  the  deltoid  at  the  lower  part,  and  then  to  divide  the  muscular  fibres 
higher  up  by  a  second  incision,  so  as  to  avoid  excess  of  muscular  tissue. 

t  But,  as  pointed  out  in  a  foot-note  below,  p.  122,  this  carrying  tiie  incision  above 
the  acromion  may  lead  to  the  protrusion  of  this  process  through  the  wound. 


122  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

being  made  to  cut  deeply  until  it  touches  the  head  of  the  humerus ;  at 
this  point  the  knife  is  carried  obliquely,  and  rather  abruptly,  out- 
wards and  downwards  to  the  centre  of  the  lower  margin  of  the  axilla 
on  the  under  surface  of  the  arm  ;  in  this  second  step  of  the  incision, 
the  tissues  are  divided  down  to  the  bone  until  the  axillary  margin  is 
reached  ;  from  this  point  to  the  termination  of  the  incision,  only  in- 
teguments are  divided,  so  that  we  may  avoid  wounding  the  axillary 
artery.  The  knife  is  again  introduced  over  the  head  of  the  humerus, 
at  the  point  where  the  perpendicular  incision  became  oblique,  and  it 
is  carried  down  upon  the  inside  of  the  arm  in  the  same  manner  as  we 
have  described  upon  the  outside.  One  assistant  pulling  asunder  the 
lips  of  the  wound  upon  the  top  of  the  shoulder,  while  a  second  carries 
the  elbow  slightly  across  the  body,  and  rotates  the  head  of  the  hu- 
merus outwards  so  as  to  expose  the  capsule  and  long  head  of  the  bi- 
ceps, the  surgeon  divides  them,  and  at  the  same  moment  the  head  of 
the  humerus  springs  from  its  socket.  The  knife  is  then  passed  under 
the  head  of  the  bone  from  above,  and,  as  soon  as  the  face  of  the  in- 
strument has  fairly  reached  the  surgical  neck,  an  assistant,  standing 
at  the  head  of  the  patient,  pushes  the  thumbs  of  both  hands  into 
the  wound  above  the  knife,  while  the  fingers  remain  in  the  axilla.  He 
thus  grasps  and  controls  the  axillary  artery.  The  operation  is  com- 
pleted by  carrying  the  knife  downwards  close  to  the  bone  until  the 
apex  of  the  integumentary  wound  in  the  axilla  is  reached,  and  then 
cutting  almost  directly  outwards.  Care  must  be  taken  not  to  sever 
the  parts  containing  the  artery  until  the  knife  has  arrived  at  the  lower 
margin  of  the  axilla." 

iii.  Amputation  by  Superior  and  Inferior  Flaps  (Figs.  35 

and  36). — The  patient  being  brought  to  the  edge  of  the  table,  turned 
sufhciently  over,  and  his  shoulders  supported  by  pillows,  the  assistants 
are  arranged  as  before.  The  arm  being  a  little  raised*  so  as  to  relax 
the  deltoid,  the  surgeon,  standing  inside  the  limb  on  the  right  side 
and  outside  it  on  the  left,  lifts  the  deltoid  muscle  with  his  left  hand 
and  sends  the  knife  (narrow,  strong,  and  no  longer  than  needful) 
across  beneath  the  muscle,  entering  it  on  the  right  side,  just  below  the 
coracoid  process,  and  bringing  it  out  a  little  below  the  most  prominent 
part  of  the  acromion,t  or  vice  versa,  according  to  the  side  operated  upon. 
The  knife  should  pass  close  to  the  anatomical  neck  of  the  humerus,  with- 
out hitching  upon  it,  and  the  flap  should  be  cut  broadly  rounded,  and 
well  down  to  the  insertion  of  the  deltoid.  It  is  then  raised  and  re- 
tracted, and,  the  capsule  being  now  exposed,  the  joint  is  opened  by 

*  If  the  surgeon  is  short-handed,  and  especially  if  the  limb  is  a  small  one,  he  can 
manipulate  the  limb  himself. 

t  Unless  care  is  taken  to  keep  thus  below  the  acromion  process,  there  will  be  some 
tendency  for  this  bone  to  protrude  in  the  wound. 


AMPUTATION    AT    THE    SHOULDER- JOIKT. 


123 


cutting  strongly  upon  the  head  of  the  bone.  The  arm  being  now  ro- 
tated upwards  vigorously  by  an  assistant  or  by  the  surgeon,  the  sub- 
scapularis,  thus  made  loose,  and  the  biceps  are  brought  into  view  and 
severed ;  the  limb  is  next  rotated  inwards,  being  carried  across  the 
chest,  and  the  muscles  attached  to  the  great  tuberosit}'  are  divided. 
The  capsule  is  next  still  more  freely  opened,  and  the  head  of  the  bone, 
now  freed,  is  pushed  up  by  the  assistant  and  pulled  away  from  the 
glenoid  cavity.  The  knife  is  next  slipped  behind  the  head  (Fig.  35), 
and  cuts  its  way  along  the  under  aspect  of  the  neck  and  shaft  of  the 
humerus  so  as  to  shape  an  inferior  flap  half  the  length  of  the  upper 
one.*     As  soon  as  the  knife  is  passed  behind  the  bone,  an  assistant 


Fig.  35. 


Fig.  36. 


J    .. 


To  show  the  manner  in  which  bleeding  is  controlled  in  the  inferior 
flap  :  the  axillary  vessels  are  compressed  by  one  thumb,  the  posterior 
circumflex  by  the  other. 


slips  his  hands  in  behind  the  back  of  the  knife  (Fig.  35),  following  it 
so  to  grasp  firmly  the  soft  parts  in  the  interior  flap,  and  thus  control 
the  axillary  vessels  (Fig.  36). 

The  large  vessels  are  next  secured,  then  the  circumflex,  and  any 
muscular  branches  that  require  it;  any  large  nerves  that  need  trim- 
ming are  then  cut  short,  drainage  provided,  and  the  flaps  brought  into 
position. 

This  amputation  has  the  advantage  of  being  very  quickly  done,  and 
of  giving  a  flap  which  keeps  in  position  by  its  own  weight,  and  thus 
gives  good  drainage.  If  the  soft  parts  below  the  humerus  are  much 
damaged,  the  upper  flap  must  be  cut  proportionately  long. 

*  The  surgeon  should  not  cut  this  till  he  is  told  that  the  flap  is  held  firmly  ;  and,  in 
cutting  it,  he  must  be  careful  of  his  assistant's  fingers. 


124 


OPEHATIOXS    OX    THE    UPPER    EXTREMITY. 


iv.  Amputation  by  Deltoid  or  Upper  Flap.— This  is  merely 

a  modification  of  tlie  last.  The  deltoid  or  upper  Hap  may  be  cut  by 
transfixion  or  made  by  cutting  from  without  inwards.  In  either 
case  it  must  be  of  very  full  size,  and  thus  is  useful  when  the  axilla  is 
damaged,  but  it  has  the  disadvantage  of  leaving  next  to  no  flap  in 
which  an  assistant  can  seize  the  axillary  vessels ;  and,  owing  to  the 
]30werful  retraction  of  the  muscles  in  the  axillary  folds,  unless  the  up- 
per flap  is  cut  full  in  length  and  size  it  will  not  cover  the  resulting 
wound.  Finally,  as  the  trunk  of  the  posterior  circumflex  is  cut, 
sloughing  of  the  large  deltoid  flap  may  take  place,  especially  if  the 
tissues  composing  it  are  at  all  damaged  previous  to  the  amputation. 
Owing  to  these  disadvantages,  which  outweigh  the  rapidity  of  disar- 
ticulation possible  by  this  method,  amputation  by  a  deltoid  flap  alone 
is  not  to  be  recommended,  a  short  under  flap  being  always  cut  if  pos- 
sible, the  deltoid  flap  thus  not  needing  to  be  made  so  long.  When 
the  surgeon,  having  disarticulated,  is  cutting  straight  down,  unable  to 
make  any  flap  below,  assistant  (2)  should  try  to  draw  up  the  skin  of 
the  axilla,  while  assistant  (3),  in  charge  of  the  limb,  should  be  careful 
not  to  draw  down  the  skin,  otherwise,  owing  to  the  laxity  of  the  skin 
in  the  axilla,  any  downward  traction  will  bring  the  skin  of  the  thoracic 
wall  under  the  knife. 

V.  Amputation  by  Anterior  and  Posterior  Flaps  (Fig. 

37}. — The  position  of  the  patient  being  as  before,  and  the  limb   being 

Fig.  37  * 


(Furgusson.) 


carried  somewhat  upwards,  backwards,  and  outwards,  the  surgeon, 
standing,  if  on  the  left  side,  behind  and  outside  the  shoulder,  enters 

*  The  knife  in  tliis  drawing  is  represented  as  far  too  large. 


AMPUTATION    AT    THE   SHOULDER- JOINT.  125 

his  knife  just  in  front  of  the  posterior  fold  of  the  axilla,  thrusts  it 
across  the  back  of  the  humerus  as  near  the  head  as  possible,  so  as  to 
get  in  front  of  the  tendons  of  the  teres  major  and  latissimus  dorsi,  and, 
bringing  it  out  close  to  the  acromion,  cuts,  with  a  sawing  movement, 
a  flap,  4  to  5  inches  long  *  which  is  next  well  retracted  by  an  assist- 
ant. The  arm  being  then  carried  across  the  chest,  the  joint  is  freely 
opened  behind,  the  muscles  attached  to  the  tuberosities  severed,  the 
knife  passed  between  the  head  and  the  glenoid  cavity  (to  facilitate 
this,  the  limb  should  now  be  carried  over  the  chest,  and  the  head  of 
the  bone  pushed  backwards),  then  between  the  bone  and  the  pector- 
alis  major,  and  an  anterior  flap,t  4  inches  long,  cut  from  within  out- 
Avards.  Haemorrhage  from  the  large  vessels  is  arrested  either  by  an 
assistant  grasping  this  flap  as  it  is  cut,  much  as  at  p.  123,  or  by  the 
surgeon  isolating  the  axillary  vessels  (the  biceps  and  coraco-brachialis 
will  guide  him)  and  securing  them  by  torsion  or  ligature  (Fig.  33)  be- 
fore he  completes  the  operation  by  cutting  the  anterior  flap.  When 
operating  on  the  right  limb,  the  patient  being  turned  well  over  on  to 
his  left  side,  the  surgeon,  standing  here  inside  the  arm,  which  is  held 
upwards  and  backwards  so  as  to  relax  the  deltoid,  lifts  this  muscle 
up  with  his  left  hand,  and  then  passes  his  knife  from  just  below  the 
acromion,  transfixing  the  base  of  the  deltoid,  grazing  the  back  of  the 
humerus,  and  finally  thrusts  the  point  downwards  and  backwards 
through  the  skin  till  it  comes  out  at  the  posterior  margin  of  the  axilla. 
This  flap,  4  or  5  inches  long,  should  be  dissected  up,  the  joint  opened 
behind,  and  the  operation  completed  as  before. 

vi.  Furneaux-Jordan  Method. — This  may  be  made  use  of  both 
as  a  primary  and  a  secondary  amputation.  The  following  are  suita- 
ble cases : 

a.  Certain  cases  of  injur}-.  "Where,  though  the  parts  about  the 
shoulder-joint  are  intact,  the  humerus  is  badly  split  up  into  the  joint. 
The  soft  parts  are  divided  down  to  the  bone  by  the  circular  method,  3 
to  4  inches  below  the  axilla,  the  main  vessel  secured,  and  the  humerus 
then  shelled  out  by  a  longitudinal  incision  along  the  outer  and  poste- 
rior aspect  of  the  limb,  meeting  the  circular  one  at  a  right  angle. 

b.  In  cases  of  failed  excision.  Here,  after  amputation  of  the  limb 
by  the  circular  method,  the  rest  of  the  bone  is  turned  out  through  the 
excision  wound  prolonged  into  the  circular  one. 

c.  After  amputation  in  the  middle  of  the  arm  in  some  cases.  E.g., 
when  the  stump  is  the  seat  of  osteo-myelitis,  necrosis,  or  otherwise 
does  not  do  well. 

*  In  the  posterior  flap  will  be  the  posterior  part  of  the  deltoid,  the  latissimus  dorsi, 
and  teres  major. 

t  In  this  anterior  flap  will  be  the  remaining  fibres  of  the  deltoid,  the  pectoralis  ma- 
jor, and  the  large  vessels  and  nerves. 


126  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

EXCISION  OF  SHOULDER-JOINT  (Figs.  38  and  39). 

This  operation  is  but  rarely  performed — (1)  owing  to  the  compara- 
tive infrequency  of  diseases  of  the  above  joint,  especially  of  pulpy 
disease,  usually  so  difficult  to  treat  save  by  operative  measures ;  (2) 
from  the  fact  that  epiphysitis  and  septic  synovitis  usually  give  after 
free  incision  and  drainage  as  good  a  result  as  can  be  obtained  after 
operation.  This  is  mainly  owing  to  the  fact  that  much  of  the  stiffness 
that  otherwise  would  be  present  is  made  up  for  by  the  supplementary 
mobility  of  the  scapula,  and  thus  the  natural  cure  may  be  expected, 
especially  in  young  subjects,  to  give  as  good  results  as  that  after 
excision.'!^ 

The  above  remarks  naturally  lead  up  to  the  consideration  of  the 
amount  of  movement  which  is  gained  after  the  operation  of  excision.  The 
arm  can  never  be  abducted  and  elevated  beyond  the  horizontal  line; 
in  the  majority  of  cases  it  hangs  close  to  the  chest.  Even  if  the  del- 
toid retained  its  power  of  elevation,  it  could  not  exert  it,  as  in  most 
operations,  owing  to  the  amount  of  bone  removed,  the  fulcrum  of  the 
head  of  the  humerus  against  the  glenoid  cavity  has  been  removed. 
Prof.  Longmore  {Resection  of  the  Shoulder-joint  in  Military  Surgery,  p.  12) 
writes :  "  The  loss  of  the  elevating  action  of  the  deltoid  must  be  ac- 
cepted, like  the  loss  of  the  rotating  power  from  the  division  of  the 
muscular  insertions  into  the  two  tubercles,  as  a  necessary  consequence 
of  resection  of  the  head  of  the  humerus.  But  the  holding  or  support- 
ing power  of  this  muscle  exerted  upon  the  whole  upper  extremity  ow- 
ing to  its  position,  its  extensive  origin,  and  the  manner  in  Avhich  it 
embraces  and  protects  the  mutilated  parts,  as  well  as  its  faculty  of  as- 
sisting in  carrying  the  arm  backwards  and  forwards,  are  all  functions 
Avhich  may  still  remain,  and  serve  to  point  to  the  great  importance  of 
I^reserving  its  integrity  as  fully  as  possible.  The  wasting  of  the  in- 
ternal fibres  (Fig.  38),  however,  seeais  a  necessary  result  of  resection 
by  the  single  incision,  but  it  has  this  compensating  feature,  that  it  is 
a  less  serious  loss  to  the  patient  than  an  atrophied  condition  of  the 
outer  and  posterior  fibres  would  be,  because  the  upper  clavicular  fibres 
of  the  great  pectoral  can  take  the  place  of  the  inner  deltoid  fibres  to  a 
considerable  extent  in  supporting  the  shoulder  and  drawing  it  forwards 
to  the  chest." 

Mr.  Erichsen  (Surgery,  \o\.  ii.  p.  251)  says  of  the  four  natural  move- 
ments of  the  shoulder-joint — viz.,  "  (1)  abduction  and  elevation,  (2) 
adduction,  (3)  and  (4)  movements  in  the  antero-posterior  direction — 


*  In  future,  by  the  use  of  a  simple  longitudinal  incision  with  a  minimum  of  inter- 
ference with  the  deltoid,  aided  by  antiseptic  precautions  from  the  first,  and  with  earlier 
and  persevering  adoption  of  passive  movements,  the  above  statement  may  have  to  be 
reversed. 


EXCISION    OF   THE    SHOULDER- JOINT.  127 

these  are  requisite  in  all  ordinary  trades  for  the  guidance  of  the  hand 
in  most  of  the  common  occupations  of  life.  The  movements  of  eleva- 
tion are  seldom  required  save  by  those  who  follow  climbing  occupa- 
tions, as  sailors,  masons,  etc.  Now,  the  mode  of  performing  the 
operations,  as  well  as  the  operation  itself,  will  materially  influence 
these  different  movements.  Thus,  if  the  deltoid  be  cut  completely 
across  by  means  of  an  elliptical  incision  the  power  of  abduction  of 
the  arm  and  of  its  elevation  will  be  permanently  lost.  If  its  fibres  be 
merely  split  by  a  longitudional  incision,  they  may  be  preserved  or 
regained  in  great  part.  All  those  movements  of  rotation,  etc.,  which 
are  dej^endent  on  the  action  of  the  muscles  that  are  inserted  into  the 
tubercles  of  the  humerus  will  be  permanently  lost;  for,  in  all  cases  of 
caries  of  the  head  of  the  humerus  requiring  excision,  the  surgeon  will 
find  it  necessary  to  saw  through  the  bone  below  the  tuberosities — in 
its  surgical,  and  not  in  its  anatomical,  neck.^  Hence  the  connections 
of  the  supra-spinatus  and  infra-spinatus,  the  teres  minor,  and  sub- 
scapularis  will  all  be  separated,  and  their  action  on  the  bone  after- 
wards lost.  But  those  muscles  which  adduct,  and  which  give  the 
antero-posterior  movements — viz.,  the  coraco-brachialis,  the  biceps, 
the  pectoralis  major,  latissimus  dorsi,  and  teres  major — will  all  be  pre- 
served in  their  integrit}' ;  and  hence  it  is  that  the  arm,  after  this  ex- 
cision, is  capable  of  guiding  the  hand  in  so  great  a  variety  of  useful 
under-handed  movements." 

Indications. 

1.  Ditierent  forms  of  arthritis  disorganizing  the  joint,  resisting  care- 
ful treatment,  in  subjects  whose  age,  general  condition,  etc.,  are  satis- 
factory— viz.  : 

(«)  Pulpy  synovitis,  resisting  other  treatment  and  going  on  to 

caries. 
(,5)  Synovitis  after  rheumatic  fever,  gonorrhoeal  rheumatism, 
wrenches,  etc.,  resulting  in  crippling  ankylosis  in  a 
young  subject. 
(>)  Ostitis  going  on  to  suppuration,  caries,  etc. 
(5)  Epiphysitis,  suppurating  or  acute  necrosis,  where  discharge, 
sinuses,  etc.,  are  exhausting  the  patient,  and  the  out- 
look as  to  natural  cure  is  not  good, 
(e)  Disease  of  the  deltoid  bursa  ulcerating  into  the  joint   and 
setting  up  destructive  arthritis. 
ii.  Gunshot  injuries,  where  the  large  vessels  and  nerves  have  escaped, 
where  fragments  of  shell,  bullets,  etc.,  are  lodged  in  the  head  of  the 

*  With  all  proper  deference  to  the  opinion  of  Mr.  Erichsen,  this  opinion  appears  to 
be  too  definite  and  inelastic.  I  would  refer  the  reader  to  tiie  remarks  below  on  the 
site  of  section  of  the  bone,  and  on  partial  resection  (p.  134). 


128  OPERATIONS    ON    THE    UPPER    EXTRE1\/ITY. 

bone,  especially  if  the  shaft  of  the  bone  is  not  much  damaged  (p. 
137). 

iii.  Compound  dislocation  and  compound  fracture  with  much  dam- 
age to  the  capsule  and  cartilage  of  the  head  of  the  bone,  the  large  ves- 
sels and  nerves  being  intact. 

iv.  Perhaps  in  cases  of  unreduced  dislocation  of  the  head  of  the 
humerus.  Mr.  Holmes  {Si/d.  of  Surg.,  vol.  iii.  p.  738),  in  a  foot-note, 
writes :  "  I  have  often  thought  that,  in  cases  of  irreducible  dislocation 
attended  with  much  pain,  the  removal  of  the  head  of  the  bone  might 
be  justifiable,  but  have  not  met  with  any  case  in  which  the  operation 
has  been  performed."  In  the  Syd.  Soc.  Bienn.  Rctr.  for  1861  is  a  very 
brief  extract  of  an  American  case  in  which  excision  was  performed 
for  an  old  dislocation  on  to  the  dorsum  of  the  scapula.  The  result  is 
not  given.  Sir  J.  Lister  {Ed.  Med.  Journ.,  March,  1873)  excised  the 
head  of  the  humerus  after  securing  a  rupture  of  the  axillary  artery, 
which  vessel  had  given  way  in  an  attempt  to  reduce  a  dislocation  of 
seven  weeks'  standing.  The  patient  sank  quickly.  Considering  the 
frequency  with  which  this  accident  has  taken  place  in  attempting  to 
reduce  old  dislocations  of  the  shoulder,  it  would  be  wiser,  in  these  days 
of  antiseptic  surgery,  to  attempt  to  improve  the  condition  of  things  by 
excising  the  displaced  head.  (While  these  sheets  are  passing  through 
the  press,  Mr.  Sheild  has  published  a  most  successful  case.) 

V.  Perhaps  in  a  few  cases  of  growth  connected  with  the  upper  extrem- 
ity of  the  humerus.  Whilst  the  priceless  value  of  the  hand  fully  jus- 
tifies the  attempt  in  some  instances,  such  cases  admitting  of  excision 
must  be  extremely  rare. 

Perhaps  it  is  owdng  to  this  rarity  that  this  matter  has  received  so 
little  attention. 

The  best  reported  English  case  with  wdiich  I  am  acquainted  is  one 
in  which  Mr.  Mitchell  Banks*  endeavored  to  save  the  upper  extremity 
of  a  patient  by  excising  the  upper  end  of  the  humerus,  the  site  of 
enchondroma : 

"  S.  D.  was  a  spare,  placid  man  of  fifty-six,  a  chapel-keeper.  So  far 
back  as  the  summer  of  1865  he  was  seized  with  violent  pain  near  the 
right  shoulder,  and  after  that  came  a  hardness  and  swelling  at  the  top 
of  the  humerus,  which  very  slowly  increased.  As  it  gave  him  no  great 
inconvenience,  he  did  not  heed  it  much  for  many  years,  but  by  1878 
it  had  grown  to  be  as  big  as  a  cocoanut,  so  that,  on  attempting  to  raise 
the  arm,  it  became  locked  against  the  acromion,  limiting  movement, 
while  pain  of  a  severe  character  set  in.     In  June,  1878, the  tumor  was 

*  Clinical  Notes  upon  Two  Years'  Surgical  Work  in  the  Liverpool  Royal  Infirmary,  p.  6. 
It  is  much  to  be  desired  that  this  original  and  most  instructive  writer  would  give  to  the 
profession,  with  equal  vigor  and  terseness,  some  more  of  liis  experience.  See  also  a 
successful  case  of  resection  for  a  central  sarcoma,  Southam,  Med.  Chron.,  .January,  1887. 


EXCISION    OF    THE    SHOULDER- JOINT.  129 

removed  by  cutting  down  upon  it,  and  dissecting  off  the  tissues  from 
over  it.  As  it  grew  from  the  outer  surface  of  the  upper  third  of  the 
humerus,  this  was  efiected  without  difficulty.  Then  with  a  mallet  and 
chisel  it  Avas  cut  cleanly  away  from  the  bone,  and  the  surface  from 
which  it  sprang  was  thoroughly  scraped — a  pretty  broad  surface,  by- 
the-way.  I  left  no  cartilaginous  remains  that  could  be  seen.  The 
patient  rapidly  recovered,  but  in  the  tract  of  the  wound  a  sinus  or  two 
persistently  remained,  leading  down  to  the  bone.  After  the  lapse  of 
about  two  years  it  became  clear  that  the  tumor  was  returning,  and  by 
the  summer  of  1881 — three  years  after  the  first  operation — it  had  attained 
an  immense  size,  having  taken  a  fit  of  growing  during  the  last  few 
months.  It  clearly  arose  from  the  same  site  as  before,  but  now  it  filled 
up  the  axilla,  and  had  even  got  beneath  the  great  pectoral.  Pain  and 
rapidity  of  growth  demanded  its  speedy  removal.  But  removal  of  a 
whole  right  arm  at  the  shoulder-joint  seemed  such  a  dreadful  thing, 
that  one  was  anxious  to  save  a  hand  and  forearm  by  carrying  away, 
if  possible,  the  tumor  and  upper  part  of  the  humerus,  even  although 
the  uj^per  arm  might  remain  useless.  The  patient  being  made  well 
aware  that,  in  case  of  the  failure  of  this  project,  there  was  nothing  left 
but  amjjutation,  I  attempted  it.  The  incisions  necessary  to  la}'^  bare 
the  tumor  were  very  extensive,  the  chief  one  reaching  from  above  the 
acromion,  half  way  down  the  outer  side  of  the  upper  arm.  With 
much  trouble,  and  after  the  loss  of  a  great  deal  of  blood,  the  outer  and 
upper  surfaces  of  the  growth  were  exposed,  and  the  humerus  was  dis- 
articulated from  the  scapula.  Then,  sawing  through  the  humerus, 
about  1  inch  below  the  deltoid  insertion,  I  attemjDted  to  dissect  away 
the  tumor  from  the  brachial  vessels  and  nerves.  Here,  however, 
inost  serious  difficulty  was  encountered,  from  their  intimate  incor- 
poratiob  with  the  growth,  and  at  last,  after  a  prolonged  attempt,  I  was 
reminded  by  my  colleague,  Mr.  Harrison,  that  the  patient  had  plainly 
endured  as  much  as  he  could,  and  that  to  make  further  effort  might 
only  lead  to  collapse  on  the  table.  I  was  reluctantly  compelled  to  ad- 
mit this,  and  so  rapidly  swept  the  limb  away  at  the  shoulder.  So 
profound  was  the  shock,  that  a  short  time  after  the  operation  the  tem- 
perature fell  to  95°,  and  remained  so  for  many  hours.  The  operation 
was  conducted  antiseptically,  and  the  patient,  in  spite  of  the  loss  of 
blood,  made  such  a  rapid  recoveiy  that  on  the  twenty-third  day  he 
left  the  infirmary  quite  well,  and  remains  so  now,  two  years  after  the 
amputation.  If  the  great  vessels  and  nerves  had  not  been  so  seriously 
enveloped  by  the  growth,  the  limb  avouIcI  have  been  saved,  although 
Avith  the  loss  of  the  upper  half  of  the  humerus.  But  even  a  forearm 
is  better  than  no  arm  at  all.  The  case  also  shows  that  chiselling  off 
cartilaginous  tumors  is  not  by  any  means  a  certain  removal.  The 
surface  that  Avas  left  upon  the  humerus,  after  the  first  removal  of  the 


130  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

tumor,  looked  perfectly  healthy  to  the  naked  eye,  Ijut  there  must 
have  been  cartilage  cells  deep  down  in  the  tissue  of  the  bone."* 

Mr.  J.  Hutchinson  has  recordedf  a  case  of  resection  of  the  upper 
part  of  the  humerus  for  a  large  myeloid  growth.  The  following  is  a 
summary  of  the  case  :  Supposed  fracture  of  the  neck  of  the  humerus 
in  a  woman,  aged  twenty-seven.  Permanent  loss  of  movement  and 
gradual  enlargement  above  the  part.  Amputation  at  the  shoulder- 
joint  advised  fourteen  months  after  the  accident,  on  account  of  a  large 
tumor  which  formed — refused  by  the  patient.  Arrest  of  the  growth 
for  four  years.  Subsequent  rapid  growth  and  enlargement  of  glands. 
Resection  of  the  upper  third  of  the  humerus,  and  removal  of  the  dis- 
eased glands.  Recovery,  with  a  useful  arm,  but  rapid  reproduction  of 
the  disease  in  four  different  parts.  Death,  five  months  after  the  resec- 
tion, from  an  enormous  mass,  with  sloughing  and  bleeding.  Second- 
ary growths  connected  with  the  bone,  axilla,  cervical  glands,  and 
lung. 

The  operation  of  resection  was  only  performed  because  amputation 
was  again  refused.  The  account  is  subjoined  :  "  Two  long  incisions 
having  been  made,  meeting  at  an  apex  a  little  below  the  insertion  of 
the  deltoid,  the  flap  of  skin,  which  was  triangular,  and  had  a  broad 
base  over  the  shoulder,  was  dissected  up.  This  flap  consisted  merely 
of  skin,  for  the  deltoid  was  found  inseparably  involved  in  fhe  growth, 
excepting  at  its  borders.  At  the  posterior  part  the  skin  also  adhered 
to  the  growth,  and  a  second  curved  incision,  including  a  crescentic 
portion  of  it,  was  accordingly  made  adjoining  into  the  outer  side  of 
the  triangle  above  and  at  its  apex.  This  done,  the  upper  surface  of 
the  growth  was  well  exposed,  and  the  next  step  consisted  in  sawing 
through  the  shaft  of  the  humerus  at  the  commencement  of  its  middle 
third,  Avhich  was  accomplished  by  means  of  a  Hey's  saw,  the  soft 
parts  being  held  away  by  retractors.  The  lateral  connections  of  the 
mass  were  next  freed — a  dissection  requiring  much  care,  as  the  vessels 
and  nerves  were  embedded  in  a  deep  furrow,  formed  by  projecting 
nodosities  of  the  growth.  Before  accomplishing  the  disarticulation,  it 
was  found  necessary  to  saw  away  the  acromion  and  the  coracoid  pro- 
cess, and  even  then  it  was  not  done  without  much  difficulty,  on  ac- 
count of  the  tumor,  in  its  growth  upwards,  having  embraced  the  artic- 
ular head  of  the  scapula,  which  was  firmly  lodged  in  a  cup  at  least  1 
inch  in  depth.  Only  one  vessel  required  ligature  (the  posterior  cir- 
cumflex) ;  it  was  of  large  size,  and  had  been  divided  very  near  to  the 
main  trunk.  The  bleeding  had,  throughout,  been  but  slight,  and  the 
patient,  when  returned  to  bed,  was  in  very  good  condition.     Tlie  large 

*  The  other  cases  of  encliondronia  of  the  upper  extremity  of  the  humerus  treated  by 
excision  of  the  joint  arealhided  to  below, 
f  Path.  Soc.  Trans.,  vol.  viii.  p.  346. 


EXCISION    OF    THE    SHOULDER- JOINT.  131 

mass  of  glands  from  the  infra-axillai\y  space  had  been  removed  by  a 
second  incision,  Avhich  did  not  join  that  for  the  resection  of  the  bone. 
A  length  amounting  to  about  one-third  of  that  of  the  shaft  of  the  hu- 
merus having  been  removed,  the  arm  was  greatly  shortened.  There 
was  no  difficulty,  however,  in  lifting  the  elbow  up,  so  that  the  upper 
part  of  the  humerus,  where  sawn  across,  came  nearly  in  contact  with 
the  glenoid  cavity,  and  in  this  position  it  was  retained  by  a  band- 
age." 

In  the  following  case,*  the  growth  being  a  more  innocent  one,  re- 
section was  more  successful : 

A  farmer  had  a  swelling  in  the  deltoid  region,  about  the  size  of  a 
hen's  egg,  very  hard,  and  considered  to  be  an  exostosis.  In  the  course 
of  a  year  it  grew  rapidly,  and  the  shoulder  now  measured  17  inches 
in  circumference.  Excision  of  the  head  of  the  humerus  Avas  performed, 
the  bone  being  sawn  through  at  the  insertion  of  the  deltoid,  the  mus- 
cles severed,  including  the  pectoralis  major  and  latissimus  dorsi,  the 
tendon  of  the  biceps  being  preserved.  Sixteen  months  later  the  pa- 
tient could  "  plant  corn  as  well  as  any  man."  There  had  been  a  slight 
reproduction  of  bone  up  to  within  2  inches  of  the  glenoid  cavity,  a 
narrow  strip  of  periosteum  having  been  preserved  along  the  inner  sur- 
face of  the  bone  almost  up  to  its  neck.  The  shortening  of  the  limb 
amounted  to  nearly  li  inch.  The  length  of  bone  removed,  including 
the  head,  measured  3 J  inches.  The  growth  was  13  inches  in  circum- 
ference at  its  largest  part,  and  proved  to  be  an  enchondroma.f 

Methods.t 

i.  By  a  straight  incision  (Figs.  38  and  39). 

ii.  By  a  deltoid  flap. 

The  first  need  only  be  referred  to  at  any  length  here.  The  deltoid 
flap  gives  more  room,  and  thus  facilitates  the  operation  considerably, 
but  the  larger  scar,  and  far  greater,  in  fact  almost  total  impairment  of 
deltoid  power,  are  such  serious  drawbacks§  that  it  is  nowadays  hardly 

*  Dr.  Bennett,  Amer.  Jour.  Med.  Sci.,  1863,  vol.  ii.  p.  385.  He,  quoting  from  Hodge's 
Excision  of  Joint.",  states  tiiat  four  cases  of  excision  of  the  slumlder  for  growtiis  are  tliere 
given.  Tluee  were  cases  of  malignant  disease,  and  were  all  unsnccessfnl,  the  patient 
either  dying  soon  after  the  operation,  or  later  on  from  a  recurrence.  The  successful 
case  was  one  operated  on  by  Mr.  Bickersieth,  for  an  exostosis  which  impeded  the  move- 
ments of  the  joint. 

f  Further  information  of  this  case  would  have  been  very  valuable.  In  two  of  the 
cases  in  which  Prof.  Syme  excised  the  scapula,  he  had  previously  excised  the  head  of 
the  humerus.  In  one,  the  growth  was  tibro-cartilnginous,  and  recurrence  did  not  take 
place  for  a  year  and  three  months.  In  the  otlier,  the  nature  of  the  growth,  a  cystic 
one,  is  not  specified  ;  recurrence  here  also  took  place,  about  a  year  later. 

X  Fourteen  different  methods  are  figured  by  M.  Pean,  loc  infra  cit. 

?  Pidf  Longmore  (loc.  supra  cit.  p  9)  says  that  at  one  time  there  were  at  Fort  Pitt 
two  [latienls,  in  each  of  whom  resection  of  the  joint  had  been  performetl,  in  one  by  the 


132 


OPERATIOXS    OX    THE    UPPER    EXTREMITY. 


ever  used.  If  the  head  of  the  humerus  is  very  much  shattered,  if  the 
soft  parts  are  much  matted  and  thickened,  if  there  is  any  special 
reason  for  completing  the  operation  rapidly,*  this  method  may,  though 
ver}^  rarely,  be  made  use  of. 

The  patient  being  rolled  a  little  over,  and  the  shoulder  supported 
by  a  pillow,  the  surgeon,  standing  at  the  shoulder  facing  the  body, 
with  an  assistant  facing  him,  and  another  seated  to  manipulate  the 
limb,  makes  an  incision,  3  inches  long,  commencing  just  outside  the 

Fig.  38. 


Excision  of  shoulder-joint  by  a  straight  incision  placed  just  outside  the  coraeoid  process.  As 
only  the  anterior  part  of  the  deltoid  is  cut,  the  posterior  circumflex  and  the  circumflex  nerve 
are  less  damaged.    (Pean.f) 

coraeoid  process,  and  on  a  level  with  it,  through  skin  and  fasci£e ;  the 
deltoid  is  then  divided  for  the  same  length,  and,  if  the  arm  has  been 
rotated  outwards,  the  bicipital  groove  will  be  seen  lying  at  the  bottom 
of  the  wound.  The  condition  of  this  important  tendon  Avill  vary 
much :  (1)  it  may  be  normal ;  (2)  it  may  be  surrounded  with  pulpy 


lon<^itudinal,  in  the  other  by  the  flap,  incision.  In  the  former  case,  the  patient  could 
raise,  without  difBculty,  f  hundredweight  with  the  arm  in  an  extended  position  by  liis 
side,  and  hold  14  pounds  in  his  hand  when  the  arm  was  flexed.  In  the  latter  case,  all 
the  movements  of  tiie  joint  were  very  seriously  impaired.  The  man  could  not,  in  any 
degree  whatever,  move  the  arm  from  the  side  himself,  nor  could  he  flex  the  forearm 
upon  the  upper  arm  without  support  from  the  other  hand. 

*  Perhaps,  too,  in  the  rare  cases  of  excision  attempted  for  large  growths,  for  the 
sake  of  more  complete  exposure  (p.  128). 

f  J.  Pean,  De  la  Scapulalgie,  et  de  la  Resection  scapula -humerale  (Paris,  1860.) 


EXCISION   OF    THE   SHOULDER-JOINT. 


133 


material;  (3)  it  may  be  frayed  an  1  adherent  to  the  bone;  (4)  it  may 
be  ulcerated  or  absent.  Whenever  it  is  possible  to  preserve  it,  it  should 
be  carefully  separated  from  its  groove  and  drawn  aside  with  a  blunt 
hook.  The  capsule  is  next  to  be  freely  opened,  and,  the  arm  being 
strongly  rotated  outwards,  the  sub-scapularis  is  divided;  then,  after 
rotation  inwards,  the  three  muscles  attached  to  the  great  tuberosity  are 
cut  through,  and  the  capsule  still  more  freely  opened. 

The  bone  maybe  divided  in  two  ways:  (1)  In  situ  {Fig.  39).     A 
blunt  director  is  passed  under  the  bone  from  within  outwards,  so  as  to 

Fig.  39. 


protect  the  soft  parts ;  the  bone  is  sawn  through  with  a  narrow-bladed 
or  osteotomy  saw,  seized  with  lion-forceps,  and  twisted  out,  the  lever- 
ing movements  of  an  elevator,  or  a  few  touches  of  the  knife,  aiding 
this.  (2)  The  head  is  first  thrust  out  of  the  wound,  and  then  sawn  off. 
This  method  is  somewhat  the  easier,  but  disturbs  the  soft  parts  more.^ 
The  former  is  perfectly  safe,  and  inflicts  less  damage  on  the  surround- 
ing tissues;  finally,  where  ankylosis  is  present,  it  may  be  most  diffi- 
cult to  thrust  the  head  out.f  Whichever  is  adopted,  the  soft  parts 
should  be  scrupulously  protected. 


*  It  must  not  be  forgotten  that  tliese  soft  parts  are  largely  made  up  of  important 
nerve  cords.  I  have  seen  this  operation  followed  by  tetanus  in  a  case  in  wliich  the 
surgeon  was  obliged  to  rely  on  most  inadequate  instruments. 

t  In  one  of  M.Ollier's  cases,  as  the  head  of  the  humerus  was  being  thrust  out  through 
the  wound,  the  bone,  which  was  very  fragile,  was  broken  across  just  above  the  condyles. 
This  accident  ultimately  exercised  no  untoward  influence  on  the  result. 


134  OPERATIONS    OX    THE    UPPER    EXTREMITY. 

Site  of  Section. — It  being  most  important  to  leave  the  humerus  as 
long  as  possible,  not  an  atom  more  than  is  needful  should  be  removed. 
The  section  should  be  made  just  below  the  articular  surface  in  every 
case  where  this  will  remove  the  whole  of  the  disease,  and  where  all  the 
head  must  go.  The  advantages  of  sawing  here  over  division  through 
the  surgical  neck  are — (1)  A  longer  humerus  is  left  to  be  brought 
against  the  glenoid  cavity,  and  aid  as  a  fulcrum  the  action  of  the  del- 
toid in  elevating  the  arm.  (2)  The  section  is  made  within  the  capsule, 
after,  of  course,  freely  opening  this,  but  not  damaging  its  attachments 
to  the  neck  of  the  bone.  (3)  The  tendons  in  the  bicipital  groove  are 
less  likely  to  be  interfered  with. 

Mr.  Davies  Colley  {Guy''s  Hoqi.  Bejis.^  3d  series,  vol.  xx.  p.  525)  re- 
lates a  case  of  partial  resection  of  the  head  of  the  humerus  followed 
by  unimpaired  movement  of  the  joint.  As  at  the  time  of  the  operation 
a  portion  of  the  head  of  the  humerus  seemed  healthy,  and  the  disease 
consisted  chiefly  of  a  carious  erosion  of  the  great  tuberosity  and  the 
adjacent  portion  of  the  articular  surfoce,  these  portions  only  Avere  re- 
moved, without  dislocating  the  head  of  the  bone.  The  part  removed 
was  chiefly  the  articular  surface  above  the  greater  tuberosity,  together 
with  what  remained  of  that  process.  The  lesser  tuberosity  appeared 
not  to  have  been  touched.  About  three-fifths  of  the  articular  surface 
was  left,  being  healthy.  There  Avas  some  erosion  of  the  bone  below 
the  epiphysial  line,  but  the  greater  part  of  the  disease  was  situated  in 
the  epiphysis.  The  section  of  the  bone  was  hard.  Seven  months  later 
the  movement  of  the  joint  was  "  perfect  in  every  direction.  He  swings 
the  arm  round  above  his  head,  and  rotates  it,  and  performs  every  ac- 
tion Avith  as  great  freedom  and  rapidity  as  with  the  left  shoulder-joint." 
On  this  matter  of  partial  excision  of  the  head  of  the  humerus,  the  re- 
marks at  pp.  133,  135,  should  be  referred  to. 

If  the  disease  extends  lower  down,  gouging  may  be  resorted  to,  or, 
if  needful,  one  or  two  further  sections*  may  be  made  till  healthy  tis- 
sue is  reached,  but,  as  in  tiie  case  of  the  elbow,  periosteal  deposits  or 
roughenings,  which  Avill  subside  when  the  irritation  is  removed,  must 
not  be  mistaken  for  disease  which  calls  for  extirpation. 

The  glenoid  cavity  is  then  examined,  and  gouged  if  carious.  Cases 
where  its  complete  removal  is  called  for  must  be  most  rare.  If  really 
called  for,  it  may  be  effected  by  an  osteotome,  or  by  cutting  bone-for- 
ceps;  but  taking  away  the  glenoid  cavity  must  interfere  with  the  at- 

*  In  cases  of  gunshot  injury,  s])linters  of  head  or  sliaft  will  have  to  be  carefully  re- 
moved, and  the  point  determined  whether  the  shaft  is  extensively  split  towards  the  el- 
bow. This  is  often  very  difficnlt  to  determine,  because  a  longitudinally  fractured  shaft 
may  be  maintained  in  an  apparently  unfractured  condition  by  the  close  apposition  cf 
the  fragment<^  and  by  ihe  periosteiun,  etc. 


EXCISION    OF    THE   SHOULDER  JOINT.  135 

tachments  of  the  biceps  and  triceps,  and  cause  risk  by  the  opening  up 
of  additional  cancellous  tissue. 

Any  vessels  which  require  it  are  then  secured— e.f/,,  branches  of  the 
posterior  circumflex  artery.  Sinuses  are  then  examined,  pulpy  tissue 
scraped  out  with  sharp  spoons,  drainage  provided,  and  the  upper 
part  of  the  wound  closed.  It  is  well,  in  inserting  the  drainage-tube, 
to  make  a  counter-puncture  at  the  back  of  the  upper  arm,  so  that 
the  site  of  the  operation  may  be  well  drained  while  the  patient  is 
recumbent. 

The  patient  for  the  first  few  days  should  have  his  shoulder  supported 
on  a  pillow,  and  wear  a  large  pad,  5  to  6  inches  thick  at  its  base,  in 
his  axilla.  By  the  end  of  the  first  week  he  should  be  sitting  up,  still 
wearing  the  pad,  and  after  a  fortnight,  earlier  if  possible,  passive 
movement  should  be  begun.  The  fingers  and  elbow  should  be  gently 
moved  from  the  very  first.  Electricity,  shampooing,  encouraging  the 
patient  (if  in  a  hospital)  to  sweep  with  a  short  brush,  carry  weights, 
constantly  practice  lifting  the  arm — anything,  in  short,  which  prac- 
tices the  patient  in  using  the  arm  and  new  joint — should  be  persever- 
ingly  made  use  of. 

Question  of  Sub-periosteal  Resection. — As  one  of  the  chief  draw- 
backs of  the  operation  is  the  poor  amount  of  abduction  and  elevation 
which  remains,  owing  in  large  measure  to  the  humerus  being  too  short 
to  be  brought  into  the  glenoid  cavity  when  the  deltoid  acts,  I  think 
that  in  this  joint  a  trial  of  the  sub-periosteal  method  should  be  care- 
fully made,  to  insure  as  much  reproduction  of  bone  as  possible.  Mr. 
Holmes  (System  of  Surgery,  vol.  iii.  p.  741),  it  is  true,  does  not  have  a 
high  opinion  of  this  method.  "  I  do  not  find  any  clear  proof,  in  the 
recorded  experience  of  operators  who  practice  sub-periosteal  excision, 
that  more  extensive  movement  is  obtained  after  that  than  after  the 
ordinary  method.  Nor  does  it  seem  probable  that  it  should  be  so. 
The  power  to  elevate  the  arm  above  the  horizontal  line  depends  on  the 
rotation  of  the  scapula,  which  carries  with  it  the  humerus,  the  two 
bones  being  for  the  moment  consolidated  in  consequence  of  their 
perfect  apposition  in  the  joint.  When  the  joint  is  destroyed,  and  a 
ligamentous  Connection  between  two  irregular  bony  surfaces  has  been 
substituted  for  it,  such  a  consolidation  is  impossible,  and  the  rotation 
of  the  scapula  will  no  longer  elevate  the  humerus.  Unless  we  could 
believe  that  the  globular  head  of  the  humerus  were  reproduced,  we 
could  not  expect  that  the  power  of  elevation  would  be  regained.  M. 
Oilier  speaks  as  if  this  reproduction  were  the  normal  result  of  sub- 
periosteal resection,  but  he  refers  to  no  dissection."  Urging,  as  I 
would  very  strongly,  the  importance  of  giving  the  sub-periosteal 
method  a  full  trial  in  this  excision,  I  would  point  out  that  M.  P6an 
(loc.  supra  cit.  p.  51  et  scq.)  quotes  Textor  as  finding,  eleven  years  after 


136  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

an  excision  of  the  shoulder,  "  a  new  fibrous  capsule.  This,  hard  and, 
as  it  were,  fibro-cartilaginous,  surrounded,  by  its  inner  surface,  the  up- 
per fourth  of  the  humerus,  and  embraced  it  so  firmly  as  to  be  separa- 
ted with  difficulty ;  by  its  outer  face  it  was  blended,  by  the  intervention 
of  fibrous  tissue,  with  the  structures  surrounding  the  joint,  and  par- 
ticularly with  the  deep  surface  of  the  deltoid  and  the  cicatrix  in  the 
soft  parts."  Allusion  has  already  (p.  69)  been  made  to  the  complete- 
ness of  the  capsule  which  may  be  met  with  after  excision  elsewhere. 
V.  Langenbeck  (Arch.f.  kiln.  Chir.,  1874,  vol.  xvi.)  gives  more  than  one 
case  in  which  the  arm  could  be  raised  vertically,  and  the  movements 
were  excellent.  While  it  is  true  that  these  were  cases  of  resection  for 
gunshot  injury,  and  therefore  the  patients  probably  healthy  adults ; 
on  the  other  hand,  preservation  of  the  periosteum  is  not  likely  to  be  so 
easily  effected  here  as  in  those  cases  where  it  is  sofbened  by  disease. 
Even  if  the  periosteum  cannot  be  completely  preserved,  an  additional 
i  inch  or  inch  in  length  gained,  an  irregular  knob  or  nodule-like  mass 
which  may  be  moulded  into  a  rudimentary  head  within  the  new  cap- 
sule, may  make  much  difference  in  the  future  mobilit}''  and  usefulness 
of  the  Ynnh. 

In  carrying  out  the  sub-periosteal  method,  v.  Langenbeck  and  Oilier 
(Traite  de  la  Regeneration  des  0«,  et  des  Resections  des  grandes  Articula- 
tions; 1867),  after  the  deltoid  has  been  divided  longitudinally  by  an 
incision  very  similar  to  that  already  given,  and  the  edges  of  the  mus- 
cle retracted,  raise  the  periosteum  on  the  inner  side  of  the  bicipital 
groove  up  to  the  inner  tuberosity,  and  then  peel  off  the  tendon  of  the 
sub-scapuiaris,  every  care  being  taken  to  keep  as  intact  as  possible  the 
connections  of  this  tendon  with  the  periosteum  and  ca^^sule.  When 
this  has  been  done,  and  the  bone  denuded  as  far  as  possible  on  the 
inner  side,  the  outer  side  and  outer  tuberosity  are  treated  in  the  same 
Avay,  and  with  the  same  precautions.  To  facilitate  the  above,  the  bi- 
ceps tendon  is  drawn  aside,  and  the  humerus  forcibly  rotated,  first  out 
and  then  inwards. 

Amount  of  Bone  that  may  be  Removed. — This  will  mainly  depend 
upon  the  amount  of  damage  done  to  the  periosteum,  the  possibility  of 
retaining  it  entire,  the  age  of  the  patient.  Dr.  Maclaren  {Lancet,  June 
7,  1873)  removed  the  head  and  85  inches  of  the  upper  end  of  the  hu- 
merus with  an  excellent  result. 

Langenbeck  mentions  a  case  in  which  the  whole  shaft  of  the  hu- 
merus necrosed,  and  was  removed,  the  elbow  joint  being  resected  at 
the  same  time,  and  yet  the  rei)roduction  of  bone  was  so  complete  that 
the  shortening  was  no  more  than  If  inch.  The  patient  was  young, 
and  growth  went  on,  though  the  bone  remained  behind  its  fellow. 
The  new  humerus  broke  several  times,  but  the  movements  of  the 


EXCISION    OF    THE   SHOULDER-JOINT.  137 

shoulder  and  elbow  were  very  satisfactory,  and  the  hand  was  capable 
of  most  delicate  movements. 

Prof.  Billroth  (Wien.  Med.  Bliitt.,  ]\Iarch  20,  1884;  Land.  Med.  Rev., 
1884,  p.  ly?)  gives  the  case  of  a  patient,  aged  twenty,  in  whom  the 
Avhole  of  the  right  humerus  was  removed  when  he  was  twelve.  Though 
the  periosteum  was  carefully  left  intact,  the  bone  did  not  form  again. 
Yet  the  forearm  was  well  developed,  and,  by  means  of  an  ingenious 
splint  and  an  artificial  shoulder  joint,  the  patient  could  use  his  arm 
and  hand  well.  Cf.  the  remarks  on  excision  in  continuity  of  the  shaft 
of  the  luimerus,  p.  101. 

Excision  of  Shoulder  in  Military  Surgery. — The  following 
points  of  practical  importance  are  taken  mainl}-  from  the  Med.  and 
Surg.  History  of  the  War  of  the  Rebellion,  pt.  ii.  p.  519  et  seq.  Dr.  Otis 
here  draws  conclusions  from  the  histories  of  885  cases,  670  being  for 
direct  injury,  and  215  for  fractures  in  near  proximity  to  the  joint  or 
for  consecutive  caries  or  necrosis. 

Excision  of  the  head  of  the  humerus,  together  with  portions  of  the 
clavicle  and  scapula — e.g.,  acromion,  spine,  coracoid  process,  glenoid 
cavity — was  performed  in  forty- two  cases.  It  is  remarkable  that  the 
mortality  is  less  in  this  group  than  in  that  of  simple  removal.  The 
following  remarks  are  quoted  from  Loeffler:  Fracture  of  the  glenoid 
cavity  is  especially  frequent  in  shot  injuries  of  the  shoulder.  This 
complication  makes  the  prognosis  of  excision  more  serious,  but  is  not 
a  contraindication.  If  only  fissures  are  present,  the  glenoid  cavity 
should  not  be  removed.  Tedious  burrowing  of  pus  is  very  likely  i:: 
these  cases. 

Partial  excision  of  the  hej^d  of  the  humerus  was  done  in  fourteen 
cases.  "  The  results  do  not  prove  that,  when  the  head  of  the  humerus 
is  grooved  or  grazed  by  a  ball,  it  is  safer  to  slice  off  the  injured  part 
rather  than  to  decapitate  the  bone.  Ankylosis  was  too  frequent 
to  permit  much  to  be  said  in  favor  of  partial  excision  in  this 
region." 

Date  of  excision  of  shoulder.  The  prima7ij  cases  were  273,  the  in- 
termediate 55  in  number,  the  results  being  far  less  satisfactory  than  in 
the  primar}', ''  and  corroborating  the  general  rule  forbidding  operations 
during  the  inflammatory  stage  after  injury,  except  under  circum- 
stances of  exceptional  urgency."  The  mortality  was  twice  as  great  as 
in  the  primary,  and  nearly  12  per  cent,  greater  than  in  the  following. 
Secondary,  twenty-six  cases,  with  a  mortality  of  50  per  cent.  The 
greater  success  of  primary  excision  can  well  be  understood.  The  con- 
dition of  the  soft  parts  is  much  more  favorable.  There  is  no  infiltration 
or  burrowing  of  pus,  no  softening  of  parts  or  degeneration  of  muscles,  no 
caries  or  ostitis — none,  in  fact,  of  those  complications  which,  in  sec- 


138  OPERATIONS   ON    THE    UPPER    EXTREMITY. 

ondary  excision,  imperil  the  life  and  usefulness  of  tlie  limb  of  tlie 
patient* 

Excisions  of  the  head  and  portions  of  the  shaft  of  tlie  humerus  as 
well,  293  cases,  in  190  of  which  the  precise  length  of  bone  excised  was 
specified.  Thus,  in  twenty-three,  4  inches  ;  in  eleven,  4j  ;  in  seven,  5; 
in  two,  5j  ;  and  in  five,  7  or  8  inches  were  excised.  While  the  artn 
was  shortened  (there  being  very  rarely  any  restoration  of  bone)  and 
feeble,  the  forearm  and  hand  were  usually  most  useful.  Wnerethe  arm 
was  flexile  and  uncontrollable,  an  auxiliary  apparatus,  such  as  the 
ingenious  ones  of  Dr.  Hudson ,t  brought  about  usually  a  great  im- 
provement. Dr.  Otis  {loc.  supra  cit.  p.  611)  states  of  shot-injury  resec- 
tions: "In  the  majority  of  cases  that  I  have  examined,  motion  in 
flexion,  extension,  and  abduction  was  tolerably  well  preserved.  I 
have  met  with  no  instance  of  true  ankylosis.  In  a  large  proportion  of 
the  cases,  the  functions  of  the  forearm  and  hand  were  but  slightly,  and 
in  many  not  at  all,  impaired.  Those  who  argue  that  the  limb  is  use- 
less after  an  excision  at  the  shoulder  because  it  dangles  by  the  side 
display  a  superficial  appreciation  of  the  considerations  to  be  taken 
into  account.  Apart  from  the  inestimable  value  of  even  a  partial  use 
of  the  hand,  the  mere  weight  of  the  limb,  though  its  motor  functions 
be  completely  destroyed,  is  of  advantage  in  preserving  the  equilibrium 
of  the  body  and  avoiding  the  distressing  deformity  consequent  on 
ablation." 


CHAPTER   VII. 
REMOVAL  OP  THE  SCAPULA. 

Indications. 

1.  New  growths. 

2.  Necrosis. 

3.  Accidents — e.g.,  railway  and  machinery  accidents. 

*  Dr.  Otis  quotes  Rupprecht,  one  of  the  German  authorities  in  the  war  of  1871,  to 
the  same  effect :  "  The  secondary  operations  were  very  much  ag<?ravated  by  deformi- 
ties gradually  appearing  after  the  injury,  through  thickening  of  the  periosteum  espe- 
cially, and  by  extensive  cavities  succeeding  abscesses.  Immediately  after  the  operation 
even,  healing  was  retarded  by  pus-formations,  sometimes  under  the  clavicle,  in  other 
instances  under  the  scapula,  again  on  the  anterior  aspect  of  the  arm.  Aside  from  the 
greater  muscular  atropliy  due  to  debility  resulting  from  antecedent,  tedious  suppura- 
tions, and  to  pain  and  loss  of  sleep;  apart,  also,  from  the  abundant  granulations  at- 
tending secondary  operations,  and  resulting  prejudicially  in  regard  to  the  future  use- 
fulness of  the  limb,  the  disadvantages  of  secondary  operations  already  adduced  were  of 
sufficient  importance  to  permit  us  to  declare  that  primary  resection  of  the  ho'ilder-joint 
is  preferable  to  the  secondary  operation." 

t  Loc.  supra  cit ,  Fig«.  449,  453. 


REMOVAL    OF    THE    SCAPULA.  139 

As  it  is  the  first  of  the  above  which  chiefly  raise  the  question  of  re- 
moval of  the  bone,  and  which  present  the  greatest  difficulties,  it  is  to 
removal  of  the  scapula  for  new  growths  that  most  of  the  following  re- 
marks will  apply. 

Partial  Removal  of  the.  Scapula.— In  a  very  few  cases  {e.g., 

for  a  simple  exostosis,  or  where  the  surgeon  is  certain  that  he  is  deal- 
ing with  an  unmixed  enchondroma  in  an  early  stage)  a  more  limited 
operation  may  be  sufficient.  The  chief  essential  points  here  are— (1) 
to  freely  expose  the  growtli  by  appropriate  flails,  so  that  the  limits 
may  be  clearly  defined  ;  (2)  to  be  provided  with  reliable  instruments 
of  keen  temper,  owing  to  the  exceeding  hardness  which  ma_y  be  met 
with  here. 

While  some  Continental  writers*  have  given  elaborate  directions  for 
partial  removal  of  the  scapula,  it  is  only  in  the  above  very  few  cases 
that  this  operation  is  likely  to  be  used  by  English  surgeons.  Mr.  Pol- 
lock, in  his  paperf  on  two  cases  of  removal  of  the  scapula,  thus  advises 
on  this  matter :  "  If  a  portion  of  the  scapula  be  removed,  it  should 
only  be  the  lower  portion.  But  even  if  this  be  attempted,  the  loss  of 
blood  would  probably  be  much  greater  than  if  the  whole  bone  were 
removed;  for  the  wound  is  more  confined,  and  the  wounded  arteries 
are  more  apt  to  retract  behind  the  bone  above,  and  offer  great  obsta- 
cles to  their  being  secured.  However,  should  the  lower  angle  be  alone 
the  seat  of  the  disease,  the  attempt  to  remove  the  lower  portion  only 
is  justifiable.  It  must,  however,  be  borne  in  mind  that,  when  a  lione 
is  once  the  seat  of  disease  which  requires  removal,  the  disease  is  very 
apt  to  recur  in  the  portion  left,  and  less  liable  to  do  so  if  the  whole 
bone  DC  removed.  Such  was  not,  however,  the  case  in  which  Sir  W. 
FergussonlJ:  operated,  though  the  disease  returned  in  Mr.  Liston's§ 
patient.  As  the  removal  of  the  whole  bone  is  not  a  more  formidable 
operation  than  the  removal  of  a  iM:)rtion  of  it,  and  as  the  patient  has 
less  chance  of  a  recurrence  of  his  disease  if  the  whole  bone  be  taken 

*  E.g.,  M.  A.  Demandre,  Des  Tameurs  de  V Omoplale  (Paris,  1873). 

t  St.  George^s  Hosp.  Report'^,  vol.  iv.  ]>.  23G. 

;J:  Lectures  on  the  Progress  of  Anatomy  mid  Surgery,  p.  45.  Tlie  mention  of  this  is 
extremely  brief — namely,  that  the  tumor  was  nearly  the  size  of  a  list,  and  involved  the 
lower  angle  of  the  scapula.  Nothing  is  said  as  to  its  nature.  It  appears  to  me  very 
probable  that  this  case  is  identical  witli  another  one  of  partial  removal  by  Sir  W.  Fer- 
gusson,  mentioned  below,  in  which  recnri-ence  did  tai\e  place. 

§  Ed.  Med.  and  Surg.  Journ.,  vol.  xvi.  p.  fiG.  The  tumor,  in  a  boy  aged  sixteen,  had 
grown  in  three  months  from  the  size  of  a  filbert  to  that  of  an  orange,  and  subsequently 
extended  witli  great  rapidity  over  tlie  lower  two-thirds  of  the  scapula.  On  attempting 
to  separate  itsattaclnnent  to  thes[)ine,  nKTit  profuse  hfemoriliage  occurred.  Tlie  scap- 
ula was  sawn  across  so  as  to  leave  merely  its  upper  portion  on  a  level  with  about  a 
third  of  the  spine.  Recurrence  took  place  within  six  weeks  of  the  operation,  and  killed 
the  patient. 


140  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

away,  it  should  be  in  a  very  exceptional  case,  and  on  some  very  pecu- 
liar merits  of  its  own,  that  the  surgeon  ought  to  undertake  the  removal 
of  a  portion  of  the  scapula." 

The  above  remarks  of  iSIr.  Pollock  are  entirely  borne  out  by  theliis- 
tories  of  cases  which  have  been  watched  after  partial  removal  of  the 
scapula  for  any  growth  save  an  exostosis. 

Thus,  in  January,  1S65,  Sir  W.  Fergusson*  removed  the  lower  two- 
thirds  of  the  scapula  for  a  sarcomatous  growth.  Recurrence  took 
place,  and,  in  the  fotlowing  November,  the  rest  of  the  scapula,  the 
greater  part  of  the  chivicle,  and  the  upper  extremity  were  taken 
away. 

Dr.  Bird,  of  Stockport,t  removed  the  lower  two-thirds  of  the  scap- 
ula for  a  growth  the  size  of  an  orange  in  the  infra-spinous  fossa,  in  a 
child  aged  ten,  the  bone  being  sawn  through  behind  the  neck  in  a  line 
with  the  supra-scapular  notch.  A  year  and  a  half  later  the  growth 
recurred  and  grew  quickly,  the  rest  of  the  scapula  being  now  taken 
away  together  with  the  hea(J  of  the  humerus,  which  had  become  adhe- 
rent to  the  scapula,  and  thus  also  required  removal.  A  year  and  a  half 
later  the  child  remained  w^ell,  the  use  of  the  hand  "in  sewing  and  writ- 
ing being  very  little  impaired." 

Mr.  Cock  X  removed  a  myeloid  tumor,  the  size  of  a  foetal  head,  from 
the  scapula,  the  greater  part  of  the  spine  being  removed  and  the 
acromial  end  of  the  clavicle.  A  recovery  took  place,  but  the  history 
is  not  carried  on  beyond  a  few  months. 

So,  too,  in  a  case  of  myxochondroma  removed  by  Prof.  Billroth,§ 
where  the  lower  angle  was  left  together  with  the  teres  major  and 
minor,  the  last  note  of  the  case  is  six  weeks  after  the  operation. 

In  the  case  of  growths,  removal  of  tlie  scapula  alone  or  together  with 
the  upper  extremity  may  be  called  for. 

The  malignancy  of  the  growths,  mostly  sarcomata,  wliich  may  call 
for  either  of  these  steps  is  well  known,  together  with  their  tendency  to 
involve  surrounding  parts  and  to  creep  into  regions  inaccessible  to  the 
surgeon.     Early  operation  is  imjDeratively  required. 

In  the  case  of  operation,  the  prognosis  will  be  best,  however  large 
the  growth,  when  the  rate  of  progress  has  been  slow,  when  the  growth 
is  uniformly  hard,  or  if  only  a  certain  amount  of  elasticity  is  combined 
with  the  hardness  (as  in  unmixed  enchondroma),  when  the  outline  is 
distinct  and  well  defined,  and  the  mass  movable  upon  the  ribs.jj 

-  Lancet,  1865,  vol.  ii.  p.  591.  t  H^i^-,  P-  69i3. 

X   Guys  Hasp.  Reports,  1856,  p.  1. 

I  Keported  by  Dr.  Nedorpil,  Lond.  Med.  Record,  March  15,  1878  ;  and  Arch.  f.  klin. 
Chir.,  Bd.  XX i. 

II  That  this  mobility  is  a  matter  of  some  importance  is  shown  by  the  following  case, 
quoted  by  M.  Sfeiillot  at  i).  550  of  his  Traite  de  MHeclne  nperatoire :  "  Nous  refiisanies 


REMOVAL    OF    THE    SCAPULA.  141 

On  the  other  hand,  the  prognosis  is  less  and  less  favorable  in  pro- 
portion as  the  outline  is  nniform  rather  than  nodulated  or  bossed,  the 
feel  semi-elastic  and  obscurely  fluctuating  instead  of  hard,  the  prog- 
ress rapid  and  attended  with  pain,  the  different  parts  of  the  scapula 
much  obscured'i'  and  its  mobility  much  impaired,  the  outline  of  the 
growth  ill  defined  and  lost  indistinctly  in  the  axilla.  Pulsation  and 
bruit,  enlarged  glands,  and  tendency  to  infiltration  of  the  skin  aie  also, 
of  course,  of  evil  omen. 

A.  Removal  of  the  Entire  Scapula  by  itself  (e.g.,  cases 

where  the  growth  is  primary  from  the  sca])ula,  and  where  there  is  no 
extension  to  the  humerus  or  into  the  axilla). — Preparations  against 
shock  should  be  taken,  the  extremities  being  bandaged  in  cotton- 
wool, the  head  kept  low,  ether  given,  and  subcutaneous  injections  of 
ether  and  brandy  being  in  readiness.  The  patient  is  placed  at  the 
edge  of  the  table  and  rolled  over  to  the  opposite  side.  If  the  growth 
is  very  vascular,  the  patient  weakly,  pressure  on  the  subclavian  is  of 
importance,  or  if,  from  the  extension  of  the  growth,  it  is  rendered  diffi- 
cult, this  may  be  effected  by  making  an  incision  down  to  and  through 
the  deep  fascia  over  the  artery  itself,  in  order  to  enable  an  assistant  to 
put  the  thumb  or  finger  directly  upon  it.f  This  may  be  done  by  a 
separate  incision,  or  by  an  extension  of  that  by  which  the  clavicle  is 
divided. 

Flaps  are  freely  turned  back,  usually  by  a  T-shaped  incision,  one 
limb  running  from  the  acromion  process  inwards  to  the  superior  angle 
of  the  scapula,  while  the  other  and  longer  is  made  at  right  angles  to 
the  first  down  to  the  angle  of  the  scapula.  In  another  case  the  sur- 
geon may  prefer  to  make  an  incision  along  the  vertebral  border  of  the 
scapula,  and  the  other  at  right  angles  to  it  across  the  centre  of  the 

un  jour  d'ojierer  nn  jeune  honitiie  atteint  cl'un  cancer  ^noinie  dii  scapulum,  dont  les 
limites  iretaient  pas  iiettenient  fixees,  et  nous  dumes  tioiis  applaudir  de  notre  absten- 
tion en  deconvrant  pins  tard,  a  la  necropsie,  cpie  la  tnmenr  avait  pen^tre  dans  la  poitrine 
et  envahi  nn  lobe  pulmonaire." 

*  In  a  very  large  scapular  sarcoma  on  wliich  Mr.  Pollock  operated,  it  is  stated  that 
■'the  mass  extended  over  the  upper  portion  of  the  scapula,  which  could  not  here  be 
traced,  and  over  the  outer  part  of  the  clavicle,  which  could  not  be  felt ;  and  also  so  far 
into  the  lower  triangle  of  the  neck  that  tiie  subclavian  artery  could  not  be  distinguished 
or  reached  by  the  finger."  The  whole  njass  was  removed,  but  the  patient,  aged  forty- 
seven,  died  on  the  sixth  day,  of  ciironic  bronchitis. 

t  As  adoi)ted  by  Prof.  Hyme  in  performing  the  old  operation  in  a  case  of  axillary 
aneurism,  p.  in.  If  the  clavicle  is  going  to  be  removed,  the  subclavian  can  be  com- 
manded by  cutting  down  on  the  clavicle,  freeing  it  from  its  attacliments  in  its  inner 
third,  [wssing a  flat  director  carefully  beneath  it,  sawing  through  the  bone  here,  and 
removing  a  portion  of  it,  the  finger  being  thus  placed  directly  on  tlie  subclavian  ( Jeaf- 
freson,  Lancet,  1874,  vol.  i.  p.  759). 


142  OPERATIONS  OX  THE  UPPER  EXTREMITY. 

growth.-'^  Flaps  thus  shaped  are  dissected  quickly  back,  care  being 
taken  not  to  oi)en  the  capsule  of  the  tumor. f 

A\'hen  the  whole  mass  is  thoroughly  exposed,  the  muscles  on  the 
vertebral  border  are  first  severed.  The  subclavian  being  now  firmly 
compressed,  the  trapezius,  levator  anguli,  and  the  rhomboidei  are  cut 
through, ;|:  the  posterior  scapular  artery  secured,  and  the  serratus  mag- 
nus  divided,  being  first  made  tense  by  lifting  the  scapula  of!"  the  ribs 
upwards  and  outwards.  The  muscles  on  the  upper  border  are  next§ 
attacked — viz.,  the  deltoid,  the  omo-hyoid,  and  the  supra  spinatus — 
and  the  supra-scapular  artery  secured.  The  acromio-clavicular  joint 
is  next  opened,  or  else  the  acromion  or  clavicle, ||  according  to  the 
extension  of  the  growth  in  this  direction,  severed  by  bone-forceps  or  a 
narrow  saw.  If  the  acromion  can  be  safely  left,  the  resulting  deform- 
ity— viz.,  dropping  of  the  shoulder  and  entire  loss  of  trapezius  action 
— will  be  lessened. 

The  lower  angle  and  the  latissimus  dorsi  (if  iiivolved)  being  freed, 
the  scapula  can  now  be  dragged  away  from  the  chest  by  slipping  two 
or  three  fingers  over  the  upper  or  vertebral  border.  Thus,  by  tilting 
the  scapula  outwards,  the  axillary  border  can  be  inspected,  the  teres 
and  infra-spinatus  muscles  severed,  the  position  of  the  sub-scapular 
artery  defined  by  a  finger  passed  beneath  it,  and  this  vessel  secured,  if 
possible,  before  it  is  cut.  The  scapula  being  still  farther  pulled  away 
from  the  chest,  the  muscles  attached  to  the  coracoicl  process  are  next 
severed,  and  the  scapula  removed  by  cutting  into  the  shoulder-joint 
and  severing  the  caj^sular  tendons  and  the  biceps  and  triceps.  The 
coracoid  process  may  become  detached  at  this  stage  if  partially  eroded 

*  If  tlie  skin  is  involved  or  nlcerated,  tlie  flaps  must  be  so  .shMi)ed  as  to  isolate  this. 

t  Pollock,  St.  George's  Hasp.  Reports,  vol.  iv.  p.  237. 

X  It  is  a  bad  sign  if  any  of  tlie  muscles  severed  are  infiltrated  with  growth.  That 
this,  however,  is  not  incompatible  with  a  good  recovery  is  shown  by  the  second  of  Prof. 
Syme's  i-d'^es  [Excision  of  the  Scapula,  ]).  28),  in  which  it  is  stated  that  "the  tumor 
weighed  between  4  and  5  pounds  ;  it  had  a  soft  consistence  and  very  suspicious  aspect, 
which  was  strengthened  by  microscopical  examination,  as  the  muscular  substance  that 
was  taken  away  along  with  the  growth  a|ipeared  to  be  loaded  with  the  germs  of  future 
disease;  but  fifteen  months  having  elapsed  since  the  operation  was  performed,  without 
the  slightest  appearance  of  relapse,  it  may  be  hoped  that  the  recovery  will  prove  per- 
manent." 

§  If  the  upper  bordereau  be  taken  before  the  axillary  one  is  dealt  with,  the  subcla- 
vian can  be  better  controlled  when  the  subscapular  artery  (a  source  of  free  hiemor- 
rhage) is  severed. 

II  Prof.  Spence  (Ed.  Med.  Journ.,  August,  1S72,  p.  178)  recommends  that  the  clavicle 
should  be  left,  not  sawn  through,  otherwise  the  head  of  the  humerus  tends  to  project 
through  the  incision,  there  being  nothing  but  skin  left,  the  overhanging  arch  of  bone 
having  been  removed.  On  the  other  hand,  sawing  the  clavicle,  while  it  leaves  a  cut 
surface  of  bone  as  a  possible  source  of  irritation,  facilitates  the  operation  somewhat,  as 
it  exposes  better  the  large  vessels  and  the  muscles  attached  to  the  coracoid  process. 


EEMOVAI.    OF    THE   SCAPULA.  143 

by  extension  of  growth*  If  this  happen,  it  mwst  be  carefully  dis- 
sected out  afterwards.f  Every  vessel  must  be  thoroughly  secured 
when  it  is  severed  ;  otherwise,  oozing  is  very  likely  to  take  place  a  few 
hours  later.;}:  If  the  anastomoses  are  free,  double  ligatures  will  be 
required. 

Ha;'morrhage  may  be  best  avoided  by  attention  to  the  following 
points :  (1)  Adequate  pressure  on  the  subclavian,  this  being  effected 
by  a  special  incision,  if  needful,  to  command  the  vessel.  (2)  Taking 
care  not  to  cut  into  the  tumor  itself  (3)  Dealing  with  the  axillary 
border  and  sub-scapular  artery  last.  (4)  By  some  it  is  recommended 
to  make  the  incisions  gradually,  not  larger  than  are  required  at  the 
time,  as  a  means  of  minimizing  the  hajmorrhage.  It  must  be  remem- 
bered, with  regard  to  this  point,  that  small  and  cramped  incisions 
interfere  with  a  free  and  rapid  hand  and  sufficient  exposure  of  the 
parts,  conditions  which  conduce  to  thorough  dealing  with  bleeding 
points,  and  thus  facing  one  of  the  chief  difficulties  of  this  important 
operation. 

Adequate  drainage  is  now  provided,  the  flaps  united,  and  the  arm 
secured  to  the  side  for  a  few  days,  after  which  it  may  be  supported  in 
a  sling  if  the  head  of  the  humerus  does  not  tend  to  protrude. 

Condition  of  the  Limb  after  Removal  of  the  Scapula.- — A 
limb  thus  preserved  will  be  strong  and  useful.  If  the  clavicle  has  not 
been  much  interfered  with,  the  clavicular  fibres  of  the  deltoid  will 
remain,  and  these,  together  with  the  latissimus  dorsi  and  pectoralis 
major,  will  probably  confer  a  fair  amount  of  motion  on  the  limb.  In 
one  of  Prof.  Syme's  cases,  after  removal  of  the  scapula  and  the  outer 
third  of  the  clavicle,  and,  by  a  previous  operation,  the  head  of  the 
humerus,  the  patient  was  able  to  lift  heavy  weights,  and  to  fill  the 
appointment  of  provincial  letter-carrier. 

In  a  very  successful  case  of  Mr.  Symonds'  (Clin.  Soc.  Trans.,  vol.  xx. 
p.  24),  in  which  the  scapula  was  removed  for  osteo-sarcoma,  the  man 
was  in  good  health  two  years  and  a  half  after  the  operation.     "  He 

*  Especially  if  the  patient  be  a  yoini<f  one,  as  in  a  case  of  Mr.  Pollock's. 

t  If  the  growth  has  involved  theaxilhiry  vessels  and  nerves,  this  outlying  portion 
may  be  dealt  with  later  on,  after  the  main  mass  has  been  separated  and  removed  If  it 
is  desired  to  remove  this  extension  of  the  disease  now  while  in  continnity  with  tiie 
scapular  growth  itself,  the  surgeon  will  have  both  his  hands  free  for  what  is  a  troub- 
lesome dissection,  by  asking  an  assistant  to  drag  the  main  mass  strongly  backwards. 
To  facilitate  this  step,  Prof.  Sy  me  {he.  supracit.,  p. 26)  placed  a  piece  of  cord  round  the 
divided  extremity  of  the  clavicle,  for  the  assistant  to  pull  upon.  The  greatest  care 
must  i>e  taken,  when  dealing  with  projections  into  the  axilla,  to  keep  the  knife,  or 
blunt  dissector,  very  close  to  the  growth,  for  fear  of  opening  the  large  vessels. 

X  In  a  case  of  this  kind,  Mr.  Berkeley  Hill  transfused  twice,  but  unsuccessfully,  tlie 
patient  dying  of  shock  and  acute  sepiictemia  in  forty-five  hours  (Brit,  Med.  Juum., 
1880,  vol.  i.  p.  487). 


144 


OPERATIONS    ON    THE    UPPER    EXTREMITY 


was  able  to  do  all  the  lighter  work  of  a  carpenter,  including  the  use 
of  a  plane.  Overhead  work  he  could  not  do."  In  this  case  the  artic- 
ular surface  of  the  humerus  had  also  been  removed  about  a  month 
later,  as  it  was  thought  to  be  the  cause  of  prolonged  suppuration  sub- 
sequent to  the  first  operation. 

B.  Removal  of  the  Scapula,  together  with  the  Upper 

Extremity  (Fig.  40). — This  operation  is  re(iuired  in  cases  where  a 
growth  has  involved  the  axilla  and  humerus  us  well  as  the  scapula,  and 

Fig.  40.* 


(After  Heatli.) 

in  a  few  cases  of  machinery  accidents.  In  the  former  case  it  may  be 
performed  on  the  following  lines,  modified  to  suit  the  case  (Fig. 
40). 

The  patient  being  prepared  and  placed  as  directed  at  p.  141,  the  sur- 
geon commences  his  incision  over  the  outer  third  of  the  clavicle,  and 
thus  can  now  either  proceed  to  secure  the  subclavian  artery  at  once, 
or  enable  an  assistant  to  put  his  finger  directly  upon  the  vessel.  In 
the  former  case  the  soft  parts  must  be  separated  with  a  raspatory,  the 
subclavius  divided,  and  the  vessels  found  beneath  it.  From  the  end 
of  this  incision,  over  the  acromio-clavicular  joint,  another  is  made 
curving  outwards  over  the  shoulder  and  upper  part  of  tlie  arm, 
and  then  sweeping  back  to  the  inferior  angle  of  the  scapula.  This 
curved  oval  flap  is  then  raised  towards  the  spine,  the  muscles  on  the 

*  This  drawing  is  based  upon  one  of  a  patient  of  Mr.  Heath's  (Brit.  Med.  Journ., 
1886,  vol.  i.  p.  66).  The  outline  of  the  flaps  has  here  been  brought  somewhat  too  low 
down  upon  the  arm. 


REMOVAL    OF    SCAPULA    AND    UPPER    EXTREMITY.  145 

vertebral  and  upper  borders  of  the  scapula  divided,  and  the  posterior 
and  supra-scapular  vessels  secured.  The  scapula,  with  the  arm,  is 
next  carried  boldly  forwards  towards  the  axilla,*  and  the  sub-scapular 
vessels  secured  and  divided,  together  with  the  muscles  in  the  axillary 
border.  A  second  incision,  the  extremities  of  which  meet  the  first,  is 
then  made  over  the  front  of  the  shoulder  and  arm,  curving  back  across 
the  axilla.  When  the  anterior  flap,  thus  marked  out,  has  been  suffi- 
ciently dissected  up,  the  large  vessels,  if  not  already  dealt  with,  are 
found  and  secured  before  their  division,  and  the  limb  and  scapula 
removed. 

All  haemorrhage  being  securely  arrested,  the  flaps  are  next  submit- 
ted to  careful  scrutiny  for  any  suspicious  infiltration,  and  the  axilla 
examined  for  any  enlarged  glands  or  outlying  masses  of  growth.  If, 
owing  to  the  necessarily  prolonged  operation  or  for  fear  of  shock,  no 
sprayt  has  been  used,  the  flaps  should  be  sponged  over  with  zinc-chlo- 
ride solution  (gr.  xx-^j)  before  being  adjusted,  due  drainage  being 
also  provided. 

Age  of  the  Patient. — It  may  be  not  uninteresting  to  some  to  know 
that  the  scapula  has  been  successfully  removed  for  growth  at  ages 
varN'ing  between  "about  seventy  "  and  "  about  eight."  The  former 
was  a  patient  of  Prof.  Syme,J  who  died  about  two  months  after  the 
operation,  apparently  of  internal  deposits.  The  latter  case  occurred  in 
India, §  the  upper  extremity  being  removed  at  the  same  time. 

Dangers  of  the  Operation  and  Causes  of  Death.— Tliese  are 
chiefly — 

1.  Haemorrhage. 

2.  Shock. 

3.  Septicaemia. 

4.  Entrance  of  air  into  veins.  This  very  nearly  proved  fatal  in  a 
case  in  which  Mr.  Jessop,  some  years  ago,  removed  the  scapula,  outer 
half  of  the  clavicle,  and  the  upper  extremity  (Brit.  Med.  Journ..  1874, 
vol.  i.  p.  12).  In  this  case  the  scapula  seems  to  have  been  removed 
owing  "  to  considerable  deficiency  of  cover  "after  removal  of  an  upper 
limb  much  damaged  by  a  machinery  accident.  "  Whilst  cutting 
through  the  last  attachments  of  the  scapula,  two  distinct  loud  whiff's 
were  heard,  caused  bv  the  rush  of  air  into  the  subclavian  vein."     The 


*  During  these  or  other  necessary  manipuhitions,  the  humerus,  if  much  invaded  by 
growth,  may  give  way. 

t  If  possible,  a  very  efficient  substitute  for  this  may  be  used  by  irrigatintj,  occasion- 
ally, tiie  wound  as  made,  with  a  h)tion  of  mercury  perchloride,  glycerine,  and  water. 

X  Loc.  supra  cit. 

I  A  very  brief  mention  of  this  case  is  c^iven  in  a  letter,  L(mcet,1^7i,  vol.  i.  p.  819.. 
It  is  not  stated  whether  the  patient  was  a  native  or  no. 

lU 


146  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

operation   was  completed  while  artificial  respiration  was  being  per- 
formed, and  the  lad  recovered. 

5.  Recurrence.  This  takes  place  usually  within  six  or  twelve 
months.  In  a  case  of  Mr.  Heath's  (loc.  swpra  cit.),  recurrence  took 
place  seven  months  after  extirpation  of  arm  and  scapula  in  a  lad  aged 
sixteen,  with  two  years'  history  of  the  growth,  an  "  osteo-sarcoma." 
The  recurrent  growth  was  removed,  but  two  years  and  a  half  after  the 
original  operation  recurrence  again  took  place,  and  was  dealt  with 
about  five  months  later.  A  rapid  recovery  took  place,  and  at  the  time 
of  this  the  latest  operation,  no  signs  of  extension  to  the  internal  organs 
could  be  detected,  and  the  patient  was  in  robust  health. 

Removal  of  the  scapula  for  caries*  needs  no  especial  mention.  The 
parts  being  sufficiently  exposed,  the  operation  will  be  conducted,  as 
far  as  possible,  sub-periosteally,  by  means  of  appropriate  blunt  dis- 
sectors or  periosteal  elevators. 


CHAPTER  VIII. 
OPERATIONS  ON  THE  CLAVICLE. 

REMOVAL  OF  THE  CLAVICLE. 

Removal  may  be  required  for  new  growths  or  necrosis.  In  either 
case  it  is  very  rarely  called  for.  That  for  necrosis  differs  in  no  way, 
save  for  the  importance  of  surrounding  parts,  from  the  same  operation 
elsewhere. 

Removal  of  Clavicle  for  New  Growths. — No  better  idea  of 
the  kind  of  operation  required,  and  the  difficulties  likely  to  be  encoun- 
tered, can  be  gained  than  from  the  account  of  Prof.  Mott's  celebrated 
case.f 

A  youth,  aged  nineteen,  consulted  Prof  Mott  in  1828  for  a  tumor 
about  4  inches  in  diameter,  very  hard,  firmly  attached  to  the  clavicle, 
which  had  been  noticed  about  four  months,  and  which  was  fungating 
owing  to  irritation  by  escharotics,  etc. 

An  incision,  begun  over  the  sterno-clavicular  joint,  was  carried,  in  a 
semicircular  direction,  as  close  to  the  fungating  part  as  was  safe,  to 
hear  the  acromio-clavicular  joint.     In  dividing  the  pectoralis  major, 

*  A  good  case  of  this  kind  is  recorded  by  Sir.  W.  Fergusson  {Med.  Chir.  Trans.,  vol. 
xxxi.  p.  310).  An  exquisite  drawing  of  tiie  scapula — one  of  the  very  best  by  the  hands 
of  the  Baggs — will  be  fonnd  in  the  same  author's  Practical  Surgery,  4tli  ed.  p.  309,  Fig. 
144. 

t  Amer.  Journ.  Med.  Sci.  (O  S.),  vol.  iii.  p.  100. 


REMOVAL    OF    THE    CLAVICLE.  147 

arteries  sprang  in  every  direction  ;  anumber  of  large  venous  branches, 
under  the  muscle,  also  required  ligature.  Care  was  taken  to  avoid 
the  cephalic  vein,  which  was  drawn  outwards.  Finding  it  impossible, 
from  the  size  of  the  tumor  and  its  close  proximity  to  the  coracoicl  pro- 
cess, to  get  under  the  clavicle  in  this  direction,  an  incision  was  made 
from  the  outer  edge  of  the  external  jugular,  over  the  tumor,  to  the  top 
of  the  shoulder.  After  dividing  the  skin,  platysma,  and  part  of  the 
trapezius,  a  sound  part  of  the  clavicle  Avas  exposed  nearer  to  the  acro- 
mion than  the  coracoid  process.  A  steel  director,  very  much  curved, 
was  now  cautiously  j^assed  under  the  bone  from  above,  great  care  being 
taken  to  keep  the  instrument  in  close  contact  with  the  bone.  The 
great  depth  of  the  clavicle  from  the  surface  rendered  it  somewhat  diffi- 
cult to  accomplish  this  safely;  an  eyed  probe,  similarly  curved,  con- 
veyed along  the  groove  of  the  director  a  chain  saw,  which,  when  moved, 
showed  that  nothing  intervened  between  it  and  the  bone  ;  the  clavicle 
was  then  readily  sawn  through. 

The  first  rib  being  next  exposed  under  the  sternal  end  of  the  clavi- 
cle, below  the  pectoralis  major,  the  rhomboid  ligament  was  divided 
and  the  joint  opened.  This  gave  great  and  encouraging  mobility  to 
the  diseased  mass. 

The  saAvn  end  of  the  clavicle  being  a  little  elevated  and  the  parts 
around  it  loosened,  the  surgeon  tried  to  discover  the  subclavius  mus- 
cle, but  it  could  not  be  seen,  being  incorporated  with  the  diseased 
mass.  Had  this  muscle  l>een  found,  the  separation  of  the  tumor 
would  have  been  much  less  difficult  and  tedious,  as,  by  keeping  above 
it,  the  subclavian  vein  is,  of  course,  protected.  The  origin  of  this  mus- 
cle was  seen  and  divided,  but  it  was  almost  immediately  afterwards 
obliterated  in  the  tumor. 

The  omo-hyoid  was  found  under  the  sterna-mastoid,  and  traced  to 
its  origin  on  the  scapuhi.  In  separating  the  tumor  from  the  cellula-r 
and  fatty  tissue  between  the  omo-hyoid  and  the  subclavian  vessels,  a 
number  of  large  arteries  were  divided,  which  bled  freely,  particularly 
a  large  branch  from  the  inferior  thyroid. 

The  anterior  part  of  the  upper  incision  was  now  made  from  the 
sternal  end  of  the  clavicle,  and  carried  over  the  tumor,  until  it  met  the 
other  at  the  external  jugular  vein.  This  vein  was  then  cut  between 
two  fine  ligatures. 

The  clavicular  part  of  the  sterno-mastoid  was  next  cut  about  3 
inches  above  the  clavicle,  and  the  anterior  scalene  exposed  by  careful 
dissection. 

The  subclavian  vein  from  the  edge  of  the  scalenus  to  the  coracoid 
process  was  so  firmly  adherent  to  the  tumor  as  to  lead  the  operator  at 
one  moment  to  believe  that  the  coats  of  the  vein  were  so  intimately 
involved   in  the  diseased  structure  as  to  render  complete  removal 


148  OPERATIONS    ON   THE    UPPER    EXTREMITY. 

utterly  impracticable.  By  the  most  cautious  proceeding,  however, 
alternately  with  the  handle  and  blade  of  the  knife,  he  finally  succeeded 
in  detaching  the  tumor  without  the  least  injury  to  the  vein.  This 
part  of  the  operation  was  attended  with  peculiar  difficulty  and  danger. 

At  every  cut  an  artery  or  vein  would  spring  and  deluge  the  parts 
until  secured  by  ligatures.  The  external  jugular  was  so  situated  in 
the  midst  of  the  bony  mass  as  to  require  division  again  here  between 
two  more  ligatures,  near  to  the  subclavian.  Near  the  sternal  end  of 
the  clavicle,  a  large  artery  and  vein  reqviired  ligature ;  they  were  con- 
sidered branches  of  the  inferior  thyroid. 

From  having  cut  through  the  clavicular  portion  of  the  sterno-mas- 
toid,  it  Avas  possible,  by  turning  the  tumor  doAvn,  to  detach  it  from  the 
situation  of  the  internal  jugular  and  left  subclavian  without  the  least 
injury  to  these  important  parts. 

To  reach  the  lower  part  of  the  tumor  as  it  extended  upon  the  thorax, 
it  was  necessary  to  separate  the  pectoralis  major  in  a  line  with  the 
fourth  rib.  The  incision  upon  the  neck  extended  from  the  sterno- 
clavicular joint,  in  a  semicircular  direction,  to  within  1  inch  of  the 
thyroid  cartilage  and  base  of  the  lower  jaw,  and  2  inches  from  the 
lobe  of  the  ear,  and  terminated  near  the  acromio-clavicular  joint. 

The  discharge  of  blood  was  so  free  at  every  step  of  the  operation 
that  about  forty  ligatvires  were  applied.  It  was  estimated  that  the 
patient  lost  from  16  to  20  ounces  of  blood.  Prof.  Mott  stated  that  the 
operation  far  surpassed  in  tediousness,  difficulty,  and  danger  anything 
which  he  had  ever  witnessed  or  performed. 

The  tumor  was  an  osteo-sarcoma,  about  the  size  of  two  adult  fists. 

The  patient  made  a  good  recovery,  and  died  fifty-four  years  after  the 
operation  from  causes  unconnected  with  this  disease.  The  use  of  the 
arm  is  said  to  have  been  complete.  Post-mortem  examination  showed 
that  f  inch  of  the  acromial  end  of  the  clavicle  was  left,  the  rest  of  the 
bone  being  occupied  by  an  adventitious  ligamentous  band.* 

Strict  observance  of  antiseptic  details  is  especially  needed  in  such 
operations,  owing  to  the  great  risk  of  diffuse  cellulitis  in  this  region. 

Mr.  Wheeler,  of  Dublin,  recordsf  a  case  of  complete  removal  of  the 
clavicle  for  osteo-sarcoma.  The  patient  was  forty-three,  and  the 
growth  extended  all  over  the  clavicle,  save  at  the  extreme  ends, 

A  curved  incision  was  made  downwards  from  the  sternal  to  the 
acromial  extremity  of  the  clavicle.  The  sterno-mastoid  and  other 
muscles  being  divided,  the  acromio-clavicular  joint  was  opened  and 
the  clavicle  dragged  up  with  lion-forceps.  The  coraco-clavicular  and 
other  liy;aments  were  then  divided,  and  the  subclavius  detached.     The 


*  Amer.  Journ.  Med.Sci.,  vol.  Ixxxv.  p.  546. 
t  Dub.  Journ.  Med.  Sri.,  Mny  1,  1885. 


UNUNITED    FEACTUEE    OF    THE    CLAVICEE.  149 

subclavian  vessels  were  exposed,  and,  with  the  thoracic  duct  (the  oper- 
ation was  on  the  left  side),  carefully  avoided.  A  vertical  incision 
was  required  upwards  into  the  posterior  triangle.  Fourteen  ligatures 
were  needed. 

The  patient  made  a  good  recovery,  and  when  seen,  ten  years  later, 
had,  to  an  ordinary  observer,  every  power  as  if  the  clavicle  had  not 
been  touched. 

Mr.  Holmes*  draws  attention  to  the  fact  that  one  case  is  on  record 
in  which  ]Mussey,t  of  Cincinnati,  removed  the  whole  clavicle  and 
scapula  for  a  tumor  recurring  after  amputation  at  the  shoulder-joint. 
The  patient  was  heard  of  in  perfect  health  thirty-four  years  after- 
wards, at  the  age  of  seventy-one.  Mussey  commenced  from  the  inner 
side,  so  as  to  tie  the  subclavian  early  in  the  operation ;  and  this  would 
probably  be  the  best  course  if  the  state  of  the  parts  would  allow  of 
it.  Mr.  Holmes  followed  the  same  course  in  a  similar  case.  The 
patient  recovered  rapidly,  but  died  from  a  recurrence.  Mussey  nearly 
lost  his  patient  from  the  passage  of  air  into  the  subclavian  vein. 

UNUNITED  FRACTURE  OF  THE  CLAVICLE. 

While  this  condition  is  extremely  rare,  it  is  of  such  importance  as 
to  claim  some  notice  here. 

An  excellent  instance,  most  successfully  treated,  has  been  recorded 
by  Mr.  Barker. J  A  boy,  aged  twelve,  was  noticed  soon  after  birth  to 
have  a  fracture  of  the  right  clavicle,  the  cause  of  this  being  uncertain. 
Up  to  nine  years  of  age  the  child  had  no  inconvenience.  He  was  then 
gradually  more  and  more  troubled  with  pressure  on  the  brachial 
plexus,  pain  down  the  arm,  and  a  tendency  of  the  fingers  to  become 
stiff  and  fixed  in  a  flexed  position  in  writing,  this  condition  soon 
amounting  to  one  of  painful  spasm,  rendering  the  waiting  quite 
illegible. 

With  a  view  of  resecting  the  false  joint,  lifting  the  inner  end  of  the 
outer  fragment  off  the  brachial  plexus,  and  waring  it  to  the  inner  frag- 
ment, Mr.  Barker  operated  as  follows : 

"  Observing  all  the  details  of  the  Listerian  method  of  antisepsis,  I 
made  a  semilunar  incision,  about  8  inches  long,  with  its  two  ends  on 
the  clavicle,  and  its  convexity  downwards.  This  corresponded  to  the 
middle  of  the  bone,  having  the  false  joint  above  its  centre.  The  flap 
of  skin  so  formed  was  turned  upw^ards  off  the  bone,  and  wdth  it  I  dis- 
sected up  some  fibres  of  the  pectoralis  with  the  object  of  securing  that 
the  nutrition  of  the  skin  should  not  be  disturbed  by  dividing  its 

*  System,  of  Surgery,  vol.  iii.  p.  743. 
t  Amer.  Jourit.  Med.  Sci.,  vol.  xxi. 
X  Clin.  Soc.  Trans.,  vol.  xix.  p.  104. 


150  OPERATIONS    ON    THE    UPPER    EXTREMITY. 

deeper  vessels.  The  bone  l)eing  thus  exposed,  a  false  joint  was  found 
between  the  broken  ends,  whieh  were  united  by  fibrous  tissue.  I  now 
divided  the  outer  end  of  the  inner  fragment  obliquely  in  a  plane  run- 
ning from  within  outwards,  and  from  before  backwards.  The  section 
was  made  with  Gowan's  osteotome,  and  was  done  very  cautiously,  so 
as  to  disturb  the  periosteum  and  soft  parts  as  little  as  possible,  and 
obviate  all  risks  to  the  vessels  running  beneath  the  clavicle.  I  then 
placed  the  osteotome  on  the  inner  end  of  the  outer  fragment,  and 
divided  it  in  a  plane  corresponding  to  that  of  the  section  of  the  inner 
fragment.  Here  my  first  cut  was  too  oblique,  and  I  withdrew  the 
blade  of  the  saw  ;  but  the  second  was  accurately  placed  and  sacrificed 
less  bone.  I  now  lifted  the  inner  end  of  the  outer  fragment  of  the 
brachial  plexus,  and  placed  its  cut  surface  resting  upon  that  of  the 
inner  portion  of  the  bone.  A  silver  wire  was  then  passed  through 
both  ends  from  before  backwards,  and  twisted  firmly.  This  seemed 
to  secure  sufficient  fixation  of  the  two  portions,  and  the  ends  of  the 
wire  were  cut,  and  the  twisted  portion  bent  level  with  the  bone.  The 
skin  was  then  united  with  ordinary  carliolized  catgut,  the  edges  of  the 
pectoral  muscle  having  been  first  brought  together  with  stitches  of 
the  same.  A  strand  of  catgut  was  also  inserted  between  the  lips  of 
the  wound  for  drainage.  No  blood  to  any  amount  was  lost,  and  the 
wound  was  a  dry  one.  I  therefore  dressed  it  with  powdered  iodoform 
and  salicylic  wool,  considering  the  latter  more  elastic  than  gauze. 
Plenty  of  ordinary  wool  was  added  for  padding,  and  overall  a  plaster- 
of-Paris  bandage  was  laid  on.  This  was  applied  over  a  webbed  vest 
precisely  as  for  spinal  caries,  and  completely  immobilized  the  arm  and 
shoulder  for  the  month  during  which  it  was  worn.  To  this  perfect 
fixation  of  the  parts  concerned,  quite  as  much  as  to  the  accurate  ap- 
position of  the  cut  surfaces  of  the  bone,  the  good  result  of  the  operation 
is,  in  my  opinion,  to  be  ascribed," 

The  dressings  were  not  disturbed  for  fourteen  days,  when  the  Avound 
was  found  united  by  first  intention,  except  at  one  point  where  the  cat- 
gut drain  was  still  unabsorbed.  There  was  not  a  drop  of  pus  any- 
where. A  similar  dressing  was  applied,  and  not  removed  for  fourteen 
days,  when  all  healing  was  comjDlete.  The  plaster  corset  was  then 
removed,  and  a  mass  of  callus  could  be  felt  at  the  seat  of  operation. 
A  week  later  the  power  of  writing  was  found  to  be  much  inproved, 
and  the  arm  became  perfect  in  all  its  functions. 


PART    II. 
THE  HEAD  AND  NECK. 


CHAPTER  I. 


OPERA.TIONS  ON  THE  SCALP. 

But  few — viz.,  those  for  large  fibro-cellular  tumors,  and  the  vascular 
tumors  known  as  aneurisms  by  anastomosis,  etc. — will  require  men- 
tion in  a  work  like  this. 


FIBRO-CELLULAR  TUMORS,  OR  MOLLUSCUM 
FIBROSUM. 

These  rare  growths  occasionally  require  removal,  on  account  of  their 
hideous  deformity.*  The  chief  points  of  importance  in  such  opera- 
tions are — (1)  The  haemorrhage.  This  may  be  terrific.t  copious,  and 
weeping  from  every  part,  owing  to  the  huge  size  of  the  growth  and  the 
vascularity  of  the  parts.  It  is  best  met  by  an  ingenious  precaution  of 
Mr.  Hutchinson's, J  who  prevented  all  arterial  haemorrhage  during  an 

*  A  good  illustration  of  these  growths  is  given  by  Mr.  Hutchinson  {Lond.  Hosp.  Re- 
ports, vol.  ii.  frontispiece),  and  another  by  Mr.  Eriohsen  [Surg.,  vol.  ii.  p.  533  .  The 
drawing  in  this  case  is  said  to  be  taken  from  a  patient  of  Sir  W.  Stokes.  This  surgeon 
figures  an  excellent  one  [Dub.  Journ.  Med.  Sci.,  vol.  Ixi.  (N.S  ),  frontispiece). 

f  It  is  so  described  by  Sir  W.  Stokes  {loc.  supra  cit.).  The  patient,  a  man  aged 
thirty-three,  in  good  condition,  almost  died  on  the  table,  Nelaton's  method  of  invert- 
ing the  head  l)eing  made  use  of  with  excellent  results. 

X  Loc.  supra,  cit.,  p.  118.  The  piece  of  scalp  removed  here  was  twice  as  large  as  the 
palm  of  the  hand.  Owing  to  the  precautions  taken,  there  was  no  arterial  hsemorrhage. 
In  Sir  W.  Stokes's  case,  the  base  of  the  growth  was  very  wide,  reaching  from  above  and 
in  front  of  the  right  ear  to  the  left  of  the  occipital  protuberance,  upwards  as  high  as 
the  vertex,  and  hanging  down  as  low  as  the  shoulder.  In  such  a  case,  Mr.  Hutchin- 
son's plan  might  be  made  use  of  by  applying  the  tourniquet  carefully  round  the  lower 
jaw  and  nape  of  the  neck  if  it  could  not  be  applied  from  the  latter  point  oblicjuely  up- 
wards on  to  the  forehead,  the  strap  being  kept  low  in  position,  if  needful,  by  loops  of 
bandage  passed  under  it  on  either  side,  and  drawn  downwards  by  assistants. 


152  OPERATIONS    ON    THE    HEAD    AND    NECK. 

extensive  operation  of  this  kind  by  applying  round  the  head,  just 
above  the  ears,  a  Petit's  tourniquet  with  a  narrow  strap.  In  a  smaller 
case,  strong  india-rubber  bands,  with  pads  over  the  chief  arteries,  may 
perhaps  be  useful.  (2)  The  need  of  maintaining  strict  asepsis.  As 
nearly  the  whole  thickness  of  the  scalp  affected  must  usually  be  sacri- 
ficed, the  pericranium  may  be  damaged  and  the  bone  necessarily  ex- 
posed, especially  during  the  tedious  process  of  granulation  by  which 
the  extensive  wound  must  usually  heal.  The  risk  of  septic  ostitis  and 
then  phlebitis  of  the  veins  of  the  diploe  is  well  known,  with  the  inevi- 
table result  of  pyaemia. 

ANEURISM  BY  ANASTOMOSIS. 

The  treatment  of  these  most  difficult  cases  is  given  under  the  head  of 
Ligature  of  the  External  Carotid. 

QUESTION  OF  OPERATIVE  INTERFERENCE  IN 
GROWTHS  OF  THE  CRANIAL  BONES  AND  DURA 
MATER. 

Under  this  heading  are  included  malignant  growths,  usually  sarco- 
matous, springing  from  the  di])loe  or  the  dura  mater,  and  having  in 
common  the  features  of  steady  progress,  penetration  of  the  skull,  and 
pulsation.  It  remains  to  be  seen  what  operative  attacks,  aided  by 
antiseptic  surgery,  may  avail  in  these  cases,  but  for  the  present,  unless 
an  opportunity  arise  for  attacking  such  growths  quite  early — e.g., 
while  the}^  are  only  of  the  size  of  a  small  nut — it  will  be  wiser  not  to 
interfere.* 

The  following  case  is  a  good  instance  of  these  growths,  though  it  re- 
mains uncertain  as  to  its  exact  origin.  The  question  of  operation,  as 
mentioned  below,  was  repeatedly  discussed  here. 

D.  E.,  aged  twenty-eight,  a  Welsh  miner,  was  sent  to  me,  in  1885,  by 
Dr.  Evans,  of  the  Rhondda  Valley.  Three  years  ago  he  had  noticed  a 
swelling,  the  size  of  a  pigeon's  egg,  in  the  centre  of  the  right  parietal 

*  Further  carefully  recorded  cases,  with  post-mortem  records,  paying  es])ecial  atten- 
tion to  tlie  possibility  of  removal,  are  much  needed  here.  An  inteiesiinfj;  case  is  puh- 
lisiied  by  Mr,  Morris  {Path  Soc.  Trans,  vol.  xxxi.  p  259).  The  dise.i.'^e  iiere  certainly 
took  six  years  in  running  its  conrse ;  other  deposits  were  present.  The  patient  died 
away  from  London.  The  growtii  is  stated  to  have  begun  in  the  diploe,  and  to  liave 
compressed,  not  involved,  the  brain.  Mr.  West  (Lancet,  1876,  vol.  i.  p.  457)  records  a 
caseof  fimgiis  of  the  dura  mater,  which  was  explored.  This  case,  liowever,  from  the 
history,  appears  to  have  been  syphilitic  ;  the  growth  was  checked,  and  disappeai-ed 
under  the  influence  of  very  moderate  pressure.  Fits  occurred  later,  and  proved  fatal. 
Deposits,  thouglit  to  be  scirrhous,  were  found  in  the  livei-. 


GROWTHS    OF   THE    CRANIUM    AND    DURA    MATER.  153 

bone  ;  for  a  year  previous  to  this  he  had  pains  in  the  head.  During 
his  work  in  the  mine,  his  head  had  received  repeated  blows,  many 
bluish  characteristic  scars  being  present.  A  month  after  tlie  lump 
appeared,  fits  began  to  occur  nightly,  and  lasted  thus  for  three  months ; 
then  they  gradually  became  fewer,  and  for  the  last  year  there  had  been 
none  at  all. 

At  a  spot  2  inches  above  the  left  ear  was  a  large  elevation  of  the 
scalp,  measuring  nearly  5}  inches  in  one  diameter,  and  about  41  in  the 
other.  There  was  no  ulceration  of  the  scalp  tissues  here,  but  unusu- 
ally large  vessels  were  to  be  felt  over  the  area  thus  prominent.  In  the 
centre  the  bones  of  the  skull  appeared  to  be  deficient  over  a  circular 
spot  the  size  of  a  shilling,  as  here  the  scalp  could  be  deeply  dimpled 
by  finger-pressure  as  if  through  a  ring  of  penetrated  cranial  bone. 
Over  this  central  gap,  pulsation  was  strongly  marked  and  rather  heav- 
ing; it  was  also  present,  to  a  less  degree,  over  the  rest  of  the  swell- 
ing. 

At  other  parts  of  the  area  of  the  growth,  especially  at  several  spots 
in  the  periphery,  was  a  remarkable  feeling  as  if  of  bony  trabecular 
structure.  It  Avas  doubtful  whether  this  was  brought  about  by  growth 
gradually  invading  a  flat  cranial  bone,  or  to  calcification  taking  place 
in  the  periphery  of  a  sarcomatous  growth. 

On  a  level  with  the  left  ear  was  an  enlarged  gland. 

Mr.  Targett,  the  surgical  registrar,  reported  that  double  optic  neuritis 
was  present,  but  no  oculomotor  paralysis.  The  reflexes  were  normal, 
and  there  was  no  loss  of  sensation  or  motion. 

There  were  no  urgent  symptoms ;  the  j^atient  had  occasional  throb- 
bing and  pain  in  the  swelling,  but  no  obstinate  headache  and  vomit- 
ing ;  he  was  able,  as  yet,  to  work,  and  stipulated  that  no  operation 
involving  risk  to  life  should  be  performed. 

For  these  reasons,  and  because,  owing  to  the  size,  duration,  and 
characters  of  the  growth,  the  risk  of  attacking  it  Avas  undoubtedly 
great,  the  patient  left  the  hospital  without  anything  being  done. 

Unless  such  a  case  can  be  seen  very  early  (and  this  is  just  the  stage 
which  does  not  come  under  the  notice  of  the  surgeon),  the  following 
would  appear  to  be  amongst  the  difficulties  and  risks  of  an  operation 
in  these  cases  : 

The  necessar}^  difficulty  and  tediousness  in  isolating  the  affected 
bone  by  sufficient  trej^hine  crowns,  and  joining  these  with  a  saw  or 
chisel.*  In  the  above  case  at  least  four  croAvns  must  have  been  re- 
moved at  thedifferent  angles  of  the  growth.  It  must  be  remembered 
that  the  overlying  soft  parts  were  extremely  vascular  and  perhaps 

*  The  use  of  the  dental  engine  in  these  cases  is  alluded  to  elsewhere  (p.  1G5). 


154  OPERATIONS    ON    THE    HEAD    AND    NECK. 

(from  the  enlars-ed  gland)  already  involved  in  the  growth.  In  isolat- 
ing and  going  wide  of  the  affected  bone,  it  was  uncertain  whether  one 
or  more  sutures  would  not  have  to  be  crossed,  and  sinuses,  such  as  the 
superior  longitudinal,  opened,  thu^  leading  to  profuse  hemorrhage  in 
addition  to  that  certain  to  be  met  with  in  dealing  with  the  soft  parts 
and  with  the  diploe  around  the  affected  l)one. 

Then,  supposing  the  bone  sufficiently  removed  wide  of  the  growth, 
in  one  or  more  pieces,  if  the  growth  were  from  the  dura  mater,  this 
membrane  must  certainly  be  dealt  with,  and  the  same  Avould  very 
likely  be  the  case  if,  originating  in  the  diploe,  the  growth  had  crept 
inwards.  In  further  isolating  the  disease,  if  it  had  merely  pressed 
upon  the  brain  and  not  involved  it,  most  delicate  work  would  be  re- 
quired :  enlarged  branches  of  the  middle  meningeal  and,  very  likely, 
dilated  sinuses  would  require  dealing  with.  If  the  disease  had  in- 
volved, instead  of  merely  displacing,  the  brain,  new  and  special  risks 
w^ould  have  to  be  encountered  just  when  the  patient's  condition, 
after  an  already  prolonged  operation,  was  least  fitted  to  bear 
them. 

Such  are  amongst  the  chief  difficulties  and  dangers  which  apjoeared 
to  me  very  likely,  if  not  certain,  to  be  met  with  as  I  thought  over  the 
question  of  operation  in  the  case  of  the  patient  just  given.  They  do 
not  appear  to  me  to  be  exaggerated. 

Moreover,  in  these  and  in  an}'  other  prolonged  operations  which 
deal  with  the  brain  and  its  membranes,  the  fact  must  never  be  lost 
sight  of  that,  what  wdth  the  necessary  interference  wdth  very  vital 
organs,  and  what  with  the  anaesthetic,  the  margin  left  to  the  jjatient 
between  life  and  death  may  be  a  very  narrow  one.* 


*  About  four  years  ago  I  had  occasion  to  explore  anrl  attempt  the  removal  of  a  gli- 
oma, proved  later  to  occupy  almost  the  entire  right  frontal  lobe  of  a  patient  at  Guy's 
Hospital.  The  pulse  failed  so  ominously  with  chloroform  that,  after  removing  one 
crown,  ether  was  given  while  the  tiephine  was  applied  again,  and  the  two  openings 
thrown  into  one.  The  substitution  of  this  anaesthetic  was  followed  by  so  much  cyano- 
sis and  jerky,  gasping,  irregular  breathing,  with  a  fixed  chest  (the  patient  was  a  young 
man,  much  emaciated  by  vomiting  and  headache,  but  free  from  any  lung-trouble), 
that  it  was  decided  to  do  no  more  that  day.  The  patient  never  "came  to,"  and  died 
comatose  a  few  hours  later.  In  this  case  there  had  not  been  time  to  interfere  with  the 
brain  and  its  membranes.  Another  patient  of  mine,  admitted  for  epileptic  seizures 
connected  with  a  huge  cancellous  exostosis  of  the  frontal  bone,  which,  as  it  proved,  was 
pressing  inwards  upon  the  brain  and  membranes,  had  been  under  observation  for  a 
fortnight,  his  diet  being  strictly  regulated.  On  the  evening  of  Christmas  Day,  his  diet 
having  been  not  unnaturally,  but  too  suddenly,  altered,  a  severe  epileptic  seizure  came 
on  ;  this  was  followed  by  coma,  rapidly  deepening  into  deatli.  I  have  elsewhere  (p. 
178)  alluded  to  the  suddenness  with  which  respiration  may  fail  in  patients  the  subjects 
of  middle  meningeal  haemorrhage. 


GROWTHS    OF    THE    CRANIUM    AND    DURA    MATER.  155 

An  attempted  removal  of  a  growth  afterwards  proved  to  spring  from 
the  dura  mater  is  thus  recorded  by  Sir  W.  Lawrence  :* 

In  this  case,  the  patient  and  her  friends  were  anxious  for  an  opera- 
tion, owing  to  their  constant  fear  of  haemorrhage  on  account  of  the 
strong  pulsation  in  the  growth,  from  the  result  of  previous  incisions 
into  it,  and  also  because  of  the  constant  headache.  Tlie  growth,  which 
was  a  comparatively  small  one,  measured  2  inches  in  diameter,  and 
Avas  situated  in  the  felt  frontal  region.  Another  swelling,  probably 
secondary,  could  be  felt  deep  seated  in  the  region  of  the  left  hip. 

An  incision,  4  inches  long,  was  made  around  the  posterior  half  of 
the  swelling,  keeping  clear  of  the  growth  by  a  considerable  margin. 
Most  violent  haemorrhage  at  once  took  place  from  numerous  vessels, 
which  could  not  be  tied  owing  to  the  density  of  the  surrounding 
structures ;  the  bleeding  was  only  partially  arrested  by  pressure,  and 
was  so  severe  that  the  patient  seemed  likely  to  sink  under  it.  The 
operation  was  completed  by  making  a  similar  incision  in  front,  and 
by  rapidly  detaching  the  growth  on  a  level  with  the  bone.  In  doing 
this,  numerous  long  spicula  were  found  in  the  base  of  the  growth,  and 
it  was  now  made  out  for  the  first  time  that  the  growth  passed  into  the 
interior  of  the  skull  through  an  opening  more  than  an  inch  in  diame- 
ter, at  the  bottom  of  which  brain-pulsation  could  be  felt.  The  appli- 
cation of  a  pad  of  lint  with  much  firmness  was  recpiired  in  order  to 
stop  the  bleeding.  The  patient  recovered  from  the  operation,  but  fits 
came  on,  and  she  died  in  about  two  months. 

The  growth  proved  to  be  a  malignant  one  springing  from  the  dura 
mater.  The  bone  around  the  opening  in  the  frontal  bone  appeared  to 
be  perfectly  healthy.  The  left  anterior  lobe  was  depressed,  but  other- 
wise both  the  brain  and  its  membranes  were  unaffected.  There  was  a 
small  outgrowth  in  the  left  pterygo-maxillary  fossa,  and  another  in 
the  left  lobe  of  the  cerebellum,  which  perhaps  accounted  for  the  pain 
Avhich  had  been  complained  of  in  the  back  of  the  head.  The  right 
humerus  was  fractured  at  the  site  of  a  secondary  deposit ;  the  swelling 
in  the  region  of  the  left  hip  was  not  examined. 

*  Med.  Times  and  Gaz.,  18o3,  vol.  ii.  p.  129. 


156  OPERATIONS    ON    THE    SKULL 

CHAPTER  II. 
TREPHINING.:^ 

OPERATIVE  INTERFERENCEi  IN  IMMEDIATE  OR 


Indications. — The  chief  of  these  are : 

i.  Compound  Depressed  Fractures. — Whether  symptoms  of  com- 
pression are  present  or  no,  these  fractures  should,  as  a  rule,  be  ex- 
plored by  reflecting  adequate  flaps,  then  elevating  any  dej)ressed 
fragments,  and  removing  any  which  are  quite  loose.  At  the  same  time 
the  surface  of  the  dura  mater,  where  exposed,  should  be  carefully 
scrutinized,  and,  together  with  the  rest  of  the  wound,  thoroughly 
cleansed. 

Operative  interference  is  indicated  in  these  cases  for  two  reasons : 
(ft)  Even  if  no  symptoms  of  compression  are  present  at  first,  second- 
ary inflammation  is  very  likely  to  follow  in  a  few  days,  it  not  having 
been  possible  by  expectant  treatment  to  completely  cleanse  the  wound. 
If,  now,  some  minute  fragment  of  the  brittle  inner  table  has  pricked 

*  I  may  take  tliis  opportunity  of  saying,  once  for  all,  that  much  of  wliat  is  written 
below  is  based  upon  a  strong  belief  that  trephining,  if  carried  out  by  careful  hands, 
and  with  a  strict  attention  to  ;tntise]itics,  is,  pe?-  se,  an  operation  of  very  slight  risk. 
This  opinion  has  been  strongly  held  by  Mr.  Walsham  in  England,  and  Dr.  Briggs, 
Prof.  Nancrede,  Dr.  Amidon  in  America,  in  f)apers  referred  to  below.  Another  writer 
on  the  same  side,  Dr.  J.  B.  Roberts  {Ann.  of  Surg.,  vol.  ii  No.  7,  p.  8),  appears  to  me 
to  weaken  his  case  by  saying  that  a  trephining,  properly  done,  is  but  little  more  risky 
than  amputation  through  a  metacarpal  bone.  It  is  true  that,  in  both,  cancellous  tissue 
is  ojiened  ;  but,  in  one,  this  contains  large  venous  channels  in  intimate  connection  with 
the  sinuses,  and  so  with  the  general  venous  system.  Moreover,  in  the  one  operation 
the  sawing  is  very  simple  ;  in  the  other,  for  reasons  given  at  p.  166,  it  is,  unless  most 
carefully  done,  very  perijous.  But  while  I  cannot  but  think  that  Dr.  Roberts  lias 
overstated  his  case,  and  thus  run  the  risk  of  leading  inexperienced  operators  to  think 
too  lightly  of  trephining,  I  would  in  no  way  seem  to  depreciate  his  most  instructive 
paper  referred  to  above.  Prof.  Nancrede,  stating  that  from  his  experience  trephining 
is  not  a  dangerous  operation,  and  that  more  patients  die  from  complications,  which 
might  have  been  prevented  by  a  timely  operation,  than  from  the  removal  of  a  disk  of 
bone,  gives  the  mortality  of  10.69  per  cent,  as  a  probably  fair  estimate  of  the  risk  of 
the  operation  per  .se.     The  above  e-itimate  appears  to  me  to  be  much  too  high. 

t  This  term  is  used  to  include  the  use  of  the  elevator  and  dressing-forceps  as  well  as 
that  of  ihe  trephine,  a  matter  which  is  alluded  to  again  below  (p.  164). 

X  By  these  terms  it  is  intended  to  make  a  distinction  between  those  cases  in  which 
operative  interference  is  made  use  of  within  a  few  days  of  a  fracture  and  those  in  which 
it  is  only  had  recourse  to  a  long  time  after  the  injury  :  see  p.  185,  Trephining  for  Trau- 
matic Epilepsy. 


TREPHINIXG    IN    SIMPLE    DEPRESSED    FRACTLTRE.  157 

the  dura  mater,  fotal  septic  meningitis  is  almost  certain.  If,  therefore, 
the  surgeon,  in  these  cases,  waits  for  evidence  of  compression  as  a 
justification  of  operative  interference,  he  will  too  often  wait  till  it  is 
too  late.  Evidence  of  the  presence  of  dirt,  especially  of  dirt  ground 
down  to,  or  into,  the  bone,  is  a  reason  for  exploring  the  wound,  even 
if  no  symptoms  of  compression  are  present,  (b)  If  the  patient  re- 
cover from  the  immediate  effects  of  the  fracture,  injury  to  the  imier 
table,  insufficient  to  cause  symptoms  at  the  time,  and  not  detectable 
save  by  an  operation,  may  be  present  all  the  time  and  cause  much 
future  trouble.  In  the  words  of  Prof.  Nancrede  :*  "  Undoubtedly, 
many  patients  recover  in  whom  the  bone  is  not  elevated,  but  in  too 
many  epilei^sy,  insanity,  chronic  cerebral  irritation,  etc.,  render  life  a 
burden,  and  operations  are  then  required  which  often  prove  useless.f 
....  Operations  for  epilepsy  show  at  times  that,  in  the  effort  to 
bridge  across  the  irregular  fragments,  and  from  the  constant  irritation 
due  to  the  cerebral  pulsation  driving  the  dura  mater  against  the  bony 
fragments,  Nature  throws  out  osteophytic  growths,  which  eventuall}' — 
perhaps  after  years— set  up  serious  trouble." 

ii.  Simple  Depressed  Fractures. — Where  symptoms  of  compres- 
sion are  present,  operative  interference  is  the  only  course  open.  But 
where  no  such  symptoms  are  present,  the  expectant  treatment  is  b}"- 
most  surgeons  held  to  be  sufficient.  We  may  perhaps  come  best  to  a 
decision  as  to  using  operative  interference  in  simple  depressed  fract- 
ures, without  symptoms,  by  dividing  them  into  the  three  following 
groups : 

1.  Where  the  depression  extends  over  a  considerable  area,  where  it 
is  slight  in  degree — e.g.,  not  more  than  a  sixth  of  an  inch,  especially  if 
the  patient  is  young  and  the  bones  yielding — expectant  treatment  is 
no  doubt  the  best. 

2.  But,  on  the  other  hand,  where  the  depression  is  limited  and  de- 
fined, wliere  the  depressed  fragment  not  only  affects  a  small  area,  but 
is  turned  down  angularly  or  edgeways,  operative  interference  should 
be  resorted  to  at  once,  even  though  no  symptoms  are  present,  and 
whether  there  is  a  wound  or  no,  to  prevent  the  onset  of  dangers,  imme- 
diate and  remote,  fully  alluded  to  later  on. 


*  International  Encyclnpcedia  of  Sargery,  vol.  v.  p.  24. 

f  Dr.  Giinn  (IVr/ns.  Anier.  Surg.  Assoc,  vol.  i.  p.  89),  speaking  of  later  trephinino; 
for  the  relief  of  old  dei)ressed  fractures,  says  :  '"  Aftliougli  results  of  these  secondary 
operations  do  not  siiow  a  flattering  percentage  of  success,  I  tiiink  that  the  reason  may 
be  looked  for  in  the  late  period  at  which  the  operation  is  performed.  It  is  rare  tliat 
the  patient  submits  to  the  dreaded  operation  till  years  have  been  wasted  in  tlie  vain 
endeavor  to  eflect  a  cure  by  medication.  In  the  meantime,  the  constant  irritation  lias 
begotten  a  permanent  impression  upon  the  brain  and  nervous  system,  wliich  i-emains 
after  the  oflTending  point  of  irritation  has  been  removed." 


158  OPERATIONS   ON    THE    SKULL. 

3.  There  is  a  large  class  of  cases  intermediate  between  the  above, 
where  the  fracture  is  a  simple  one,  wliere  syniptoms  are  aV)sent,  and 
where  the  depression  is  sufficient  to  cause  anxiety,  though  not  so 
sharply  defined  as  to  call  imperatively  for  operation. 

In  these  cases,  if  the  surgeon  decide  to  wait  for  symptoms,  he  can 
appeal  to  an  arra}^  of  great  names  who  concur  in  putting  aside  opera- 
tive interference  in  these  cases.  But  it  is  impossible  to  write  on  this 
matter  in  1887  without  seeing  that,  owing  to  the  introduction  of  anti- 
septics and  the  lessening  dread  of  operations  on  the  skull  and  brain, 
the  pendulum  of  opinion,  which  has  for  so  many  years  swung  in  the 
direction  of  non  interference,  is  now  coming  back  towards  the  oppo- 
site view.  While  it  is  much  to  be  desired  that,  in  this  as  in  other 
cases  where  modern  surgery  seems  likely  to  reverse  the  weighty  opin- 
ion of  those  who  have  gone  on  before  us,  no  change  in  practice  shall 
be  made  hastily,  the  following  points  are  worthy  of  attention  : 

It  is  possible  that  the  compound  character  of  a  fracture  of  the  skull 
has  been  too  much  made  the  determining  touchstone  in  deciding 
whether  to  operate  or  no.  In  otlier  words,  have  not  surgeons,  while 
rightly  looking  upon  compound  depressed  fractures  as  foreshadoAving 
meningitis  and  encephalitis,  too  much  overlooked  the  fact  that  simple 
fractures  without  symptoms  may  lead  to  future,  though  perhaps  much 
more  distant,  trouble  by  the  gradual  formation  of  irregularities,  if  not 
of  osteophytes,  on  the  inner  surface  of  the  skull  ?  And  with  regard 
to  this  point,  has  not  the  fact  that,  when  both  tables  are  injured,  the 
comminution  and  displacement  of  the  internal  is  usually  by  far  the 
worst,*  been  overlooked,  or,  at  least,  under-estimated ;  a  confusion 
being   perhaps  made   between    this  fact   and   another   equall}^  well 

*  The  following  remarks  of  Dr.  Roberts  (Ann.  of  Surg.,  vol.  ii.  No.  7,  p.  14)  are  well 
worthy  the  attention  of  the  practical  surgeon.  Having  pointed  out  that  both  fatal  en- 
cephalitis, or,  later  on,  epilepsy,  mental  impairment,  etc.,  are  often  due  to  "  spicula- 
tion  "  of  the  inner  table,  he  goes  on  to  say, ''  Hence  it  follows  that  explor.atory  perfora- 
tion of  the  craninni  is  justifiable  in  all  cases  where  the  nature  of  the  impinging  force 
or  the  appearance  of  the  external  table  renders  spiculation  of  the  inner  table  probable; 
provided  that  less  danger  to  life  and  health  is  inherent  in  perforation  than  in  the  prob- 
able spiculation 1  am  driven  to  the  conclusion  that  exploratory  perforation  to 

determine  the  absence  or  [iresence  of  internal  spiculation  is  often  demanded  by  the 
uncertainty  of  the  invisible  condition.  Withouta  knowledgeof  the  true  state  of  afiairs 
treatment  is  empirical ;  and  the  risk  to  subsequent  mental  health  or  to  life  is  too  great 
to  permit  reliance  upon  empirical  treatment  when  a  knowledge  of  the  true  condition  is 
obtainable  with  the  slight  danger  fliat  pertains  to  antiseptic  trephining.  Whenever 
the  fracture,  whether  originally  an  open  one  or  so  made  by  any  incision,  presents  the 
possibility  of  the  inner  table  being  detached  and  splintered  more  extensively  than  the 
outer,  I  should  be  incliued  to  advise  perforation.  In  other  words,  I  would  cut  the  scalp 
to  see  the  condition  of  the  outer  table,  and  I  would  cut  the  bone,  to  see  the  condition 
of  the  inner  table,  in  every  case  where  the  risk  of  obscure  knowledge  is  greater  than 
the  risk  of  divided  scalp  and  perforated  bone." 


TREPHINING    IN   SIMPLE    DEPRESSED    FRACTURE.  159 

founded,  that  injury  to  the  mternal  table  alone  is  very  rare.  Perhaps, 
too,  surgeons,  because  little  or  no  callus-material  is  found  uniting 
fractures  of  the  base,  have  taken  it  as  too  much  for  granted  that  the 
same  takes  place  invariably  in  fractures  of  the  vault. 

However  these  questions  may  be  decided,  it  will  be  agreed  that  all 
surgeons  departing  from  the  time-honored  rule  of  non-interference  in 
simple  depressed  fractures  without  symptoms,  must,  by  paying  careful 
attention  to  the  following  points,  make  certain  of  not  bringing  dis- 
repute on  trephining  or  elevation  of  bone : 

1.  That  a  freer  use  of  the  trephine  in  doubtful  cases  can  be  justified 
alone  by  keeping  the  w^ound  strictly  aseptic  throughout. 

2.  Any  coexisting  conditions  which  -would  contraindicate  the 
operation  must  be  carefully  looked  for — viz.,  (^1)  Severe  and  pro- 
longed concussion;  (2)  Encephalitis  ;  (3)  Injury  to  the  base. 

Influence  of  Site. — It  is  often  said  that  a  depressed  fracture,  even  if 
distinctly  marked,  over  the  frontal  sinuses,  does  not  require  operative 
interference,  and  that  any  such  steps  should  be  avoided  for  fear  of 
leaving  a  fistulous  opening  leading  to  passage  of  air  and  troublesome 
emphysema.  But  it  must  ])e  remembered  that  these  sinuses  do  not 
appear  before  the  age  of  fifteen  or  sixteen,  and  that,  even  in  adult 
skulls,  the  extent  of  their  development  is  most  uncertain,  the  sinuses 
being  sometimes  represented  by  a  small  unilateral  cell  instead  of 
fair-sized  bilateral  cavities.*  Other  sites,  which  it  is  well  to  avoid  in 
trephining,  if  possible,  are  the  position  of  large  sinuses,t  that  of  the 

*  Hilton,  Guy's  Hasp.  Reports,  2J  series,  vol.  viii.  p.  362.  JVo^es  on  the  Cranium,  p. 
8  et  seq. 

f  It  is  worth  wliile  to  bear  in  mind  that  if  a  hirge  venous  sinus  is  opened  into,  the 
haemorrhage  is  usually  at  once  arrested  bv  very  moderate  pressure  applied  at  the  right 
spot.  The  pressiu-e  should  be  made  by  a  carbolized  finger  or  sponge,  and  kept  up  if 
needful  by  a  pad  of  dry  aseptic  gauze  dusted  with  iodoform,  left  in  situ  for  two  or 
three  days  if  possible.  Dr.  Cameron  [Lancet,  1884,  vol.  i.  p.  931)  was  able  to  complete 
a  trephining  while  very  slight  pressure  with  lint  controlled  tiie  bleeding  from  a 
wound  in  the  superior  longitudinal  sinus.  He  points  out  that  the  imaginary  fear  of 
fatal  haemorrhage  from  such  a  wound  may  at  times  deter  from  a  necessary  operation 
with  the  trephine,  and  it  is  well  that  it  should  be  dissipated.  Dr.  Hopkins  [Ann.  of 
Surg.,  vol.  ii.  No.  7,  p.  67),  in  a  case  of  extensive  compound  fracture  of  the  skull, 
found  that  a  small  lint-compress,  dusted  with  iodoform,  lightly  applied  to  a  wound 
in  the  superior  longitudinal  sinus  exposed  by  elevation  of  fragments,  readily  arrested 
the  hcemorrhage,  which  persevering  eflbrts  with  tenaculum-forceps  had  failed  to  check 
with  a  ligature.  In  other  cases,  a  wound  of  this  sinus  has  been  closed  by  sutures  of 
catgut.  Tlius,  Dr.  Parkes  {Ann.  Anat.  and  Surg.,  vol.  viii.  p.  118),  in  treating  a  wound 
caused  by  a  fracture  of  the  skull,  arrested  the  terrific  haemorrhage  first  by  pressure, 
and  then  by  introducing  three  fine  catgut  sutures.  These  entirely  closed  the  rent  and 
controlled  all  bleeding,  and  though  the  calibre  of  the  sinus  was  reduced  fully  one- 
third,  and  the  sinus  bulged  markedly  at  the  anterior  extremity  of  the  sutured  wound 
showing  interference  with  the  backward  blood-flow,  there  was  no  evidence  of  cerebral 


160  OPERATIONS    OX   THE    SKULL. 

trunk  and  chief  branches  of  the  middle  meningeal  artery,*  and  also 
the  lines  of  the  sutures,  apart  from  any  subjacent  sinuses,  as  here  the 
dura  mater  is  firmly  attached,  unless  it  chanced  to  be  loosened  by  a 
violent  blow.  Age,  too,  must  have  proper  weight  attached  to  it,  it 
being  well  known  that  in  the  first  few  years  of  life  a  very  considerable 
depression  may  take  place  after  an  injury,  and  yet  be  followed  by 
absence  of  head-symptoms  and  by  spontaneous  recovery.! 

iii.  Punctured  Fractures.— Here,  however  slight  is  the  injury  to 
the  outer  table,  that  inflicted  upon  the  inner  is  certain  to  be  much 
more  serious.  And  the  more  the  diploe  is  present,  the  more  extensive 
will  be  the  damage  which  driven-down  fragments  of  this  will  inflict 
upon  the  brittle  inner  table.  It  must  be  remembered  that  punctured 
fractures,  with  all  their  serious  results,  may  be  caused  by  blunt, 
though  pointed,  bodies,  as  well  as  by  sharp  ones.;}:  Instances  of  these 
are,  blows  with  a  pickaxe,  fragments  of  brickbat,  coal,  stone,  the 
trigger  of  a  clubbed  gun,  or  falls  on  a  fender-ornament.  Immediate 
operative  interference — and  here,  owing  to  the  limited  injury  to  the 
outer  table,  the  trephine  will  be  called  for — is  imperatively  demanded 
in  all  punctured  fractures,  however  insignificant  is  the  damage  to  the 
scalp  and  outer  table. 

iv.  In  some  Cases  of  Fracture  about  the  Inner  Angle  of  the 
Orbit. — The  trejihine  should  always  be  used  (together  with  a  small 
gouge)  in  exploring  those  grave  injuries  Avhich  may  be  caused  by 
direct  violence  from  thrust  wounds  at  the  inner  angle  of  the  orbit,  or 
root  of  the  nose — e.g.,  with  scissors,  slate  pencils,  ferrules  of  walking- 
sticks,  etc. 

The  ajjparent  slightness  of  these  injuries,  the  trifling  wound,  the 
period  of  latency  of  symptoms,  and  the  onset  of  fatal  brain  mischief — 
inevitable,  though  delayed,  if  let  alone — are  all  well  shown  in  the 
following  case  of  Mr.  Hulke's  :  § 

disturbance  due  to  tliis  interference  with  so  large  a  column  of  blood,  the  wound  heal- 
ing well  with  antiseptic  precautions.  Dr.  Brinton  (Phil.  Med.  Times,  vol.  xii.  p.  577), 
quoted  by  Dr.  Roberts  {loc.  supra  cil.).  applied  a  lateral  ligature  successfully  to  tiie 
lateral  sinus.  Tiie  strictest  antiseptic  precautions  should  be  made  use  of  in  dealing 
with  wounds  of  these  sinuses  owing  to  the  great  risk  of  septic  phlebitis  and  pyaemia. 

*  The  treatment  of  hsemorrhage  from  the  middle  meningeal  artery  is  given  at  p. 
]83. 

t  Good  instances  of  this  are  given  by  Mr.  Le  Gros  Clark  [Diagnosis  of  Visceral 
Lesions,  p.  94) ;  Mr.  Bryant  {Surpery,  2d  ed.  vol.  ii.  p.  357) ;  Prof.  Nelaton  {Pathologie 
Chirwyicale,  tome  ii.  p.  149).     The  two  last  are  accompanied  by  illustrations. 

X  Prof.  Nancrede  (loc.  supra  cit.,  p.  18)  points  out  that  a  punctured  fracture  caused 
by  a  sharp  instrument  may  consist  of  merely  a  s{)litting  off  of  a  small  scale  of  the 
inner  table,  but  that  a  blunt-pointed  body  will  comminute  the  inner  table  extensively 
by  breaking  up  the  diploe. 

^  Syst.  of  Surg.,  vol.  i.  p.  586.  As  here  pointed  out,  the  injury  is  especially  likely 
to  be  overlooked  if  the  instrument  has  slipped  under  the  lid,  and  so  reached  the  roof 


REMOVAL    OF    FOREIGX    BODIES    FROM    THE    SKULL.  161 

"  A  little  girl,  aged  six  years,  falling,  with  a  piece  of  slate  pencil 
in  her  hand,  it  pierced  her  right  eyebrow  near  its  inner  end,  and 
broke  short  off.  Admitted  soon  after  into  the  Middlesex  Hospital, 
the  house  surgeon  took  out  of  the  wound  several  splinters  composing, 
he  thought,  the  whole  piece,  covered  the  wound  with  a  pad  of  lint, 
and  had  the  child  placed  in  bed.  Her  general  condition  did  not 
betray  the  serious  nature  of  the  injury.  She  slept  quietly  through 
the  night,  and  next  morning  did  not  appear  much  worse  for  the 
accident.  In  the  afternoon,  when  I  then  first  saw  the  child,  I  detected 
with  the  probe  another  splinter  of  the  pencil,  and  enlai'ging  the  little 
l^uneture  exposed  a  piece  of  pencil  tightly  plugging  a  hole  in  the 
bone.  Enough  of  this  was  cut  away  cautiously  with  a  gouge  to  allow 
the  pencil  to  be  grasped  with  a  forceps.  It  proved  to  be  shattered, 
and  splinters  representing  a  cylinder  three-quarters  of  an  inch  long 
were  removed.  Intracranial  inflammation  (indicated  by  convulsions, 
delirium,  a  high  temperature — 103° — and  rapid  pulse)  supervened. 
On  the  ninth  day  after  the  injury  the  temperature  fell  to  97.5°  (the 
child  had  passed  a  quiet  night,  and  took  her  food  better),  and  from 
this  date  it  continued  subnormal,  or  only  slightly  exceeded  the  nor- 
mal average,  .until  the  sixteenth  day,  when  it  rose  suddenly  to  104°. 
With  this  elevation  of  temperature  were  associated  restlessness, 
delirium,  a  flushed  fjice,  screaming,  vomiting,  convulsions,  and  coma. 
Death  occurred  about  twenty-four  hours  later.  At  the  necropsy  a 
large  abscess  was  found  in  the  frontal  lobe  of  the  right  hemisphere. 
It  inclosed  a  piece  of  pencil  about  one  inch  long,  and  it  had  evidently 
quite  recently  burst  into  the  anterior  horn  of  the  lateral  ventricle.  It 
is  a  matter  of  regret  that  the  trephine  was  not  employed  instead  of 
cutting  awny  the  bone  around  the  pencil,  which  had  the  effect  of 
loosening  the  splinters,  and  contributed  to  the  fatal  mistake  that  the 
whole  piece  of  pencil  had  been  removed." 

V.  For  the  Removal  of  Foreign  Bodies  Fissuring  or  Fracturing 
THE  Skull. — These  are  rare — e.g.,  penknife-blades,  pieces  of  stone, 
bullets,  etc.  To  insure  certainty  of  complete  removal  the  trephine 
will  usually  be  required. 

The  following  cases  show  how  the  gravest  results  may  ultimately 
follow  on  the  overlooking  of  a  small  piece  of  knife-blade.  The  first 
case  is  an  instance  of  the  long  time  which  occasionally  intervenes 
between  the  injury  and  the  onset  of  urgent  symptoms  due  to  abscess. 
The  second  case  is  an  excellent  instance  of  the  history  of  a  cerebral 
abscess,  though  here,  too,  the  symptoms  were  delayed  unusually  long. 


of  the  orbit  and  base  of  the  skull,  leaving,  it  may  be,  merely  a  patch  of  ecchymosis  on 
the  conjunctiva. 

11 


162  OPERATIONS    ON    THE    HEAD    AND    NECK. 

The  first  case  is  given  by  M.  Dupuytren.*  "  II  y  a  liuit  ou  dix  ans, 
iTn  jeune  homme  reyut  dans  une  querelle  un  coup  de  couteau  sur  le 
sommet  de  la  tete ;  ce  couteau  se  rompit  dans  la  crane,  apres  I'avoir 
perfore.  I-e  chirurgien  qui  pansa  le  malade  n'examina  point  avec- 
tout  le  soin  desirable  I'etat  de  la  plaie  ;  il  en  rapprocha  les  bords,  et 
le  malade  guerit.  Plusieurs  annees  se  passerent  sans  accidents ; 
seulement,  de  temps  en  temps,  le  malade  ressentait  des  douleurs  dans 
sa  cicatrice.  Au  bout  de  quelqucs  annees,  sans  cause  connue,  il  lui 
souvait  un  assoupissement  tresfort  de  la  fievre ;  il  vint  a  I'Hotel-Dieu 
et  y  fut  reyu.  En  examinant  sa  cicatrice,  je  sentis  quelle  etait  soule- 
vee  et  dessous  elle  un  corps  etranger;  j'incisai  etfis  Textraction  cl'une 
portion  pointue  de  lance  de  couteau,  a  I'aide  du  trepan.  Les  accidents 
persisterent,  il  s'y  joignit  la  paralysie  du  cote  du  corps  oj^jDOse  ji  celui 
de  la  tete  qui'  etait  blesse.  J'incisai  la  dura  mere,  il  ne  sortit  rien ;  je 
plongeai  un  bistouri  avec  precautions  dans  le  cerveau,  et  il  jaillit  cle 
suite  un  flot  de  pus.  Le  soit  meme  de  cette  operation,  tous  les  acci- 
dents disparurent ;  la  fievre,  la  somnolence  et  le  delire ;  et  le  malade 
guerit." 

In  the  following  case  of  Prof.  Nancrede's,t  the  apparent  slightness 
of  the  injury,  the  long  absence  of  symptoms,  then  their  sudden  onset, 
the  difficulties  met  with  during  trephining,  the  results  of  promptly 
meeting  them,  and  finally  death  brought  about  by  hernia  cerebri  are 
all  deserving  of  most  careful  attention. 

On  March  6th,  J.  Y.,  aged  nineteen,  walked  into  the  Episcopal  Hos- 
pital, complaining  of  a  sore  on  the  top  of  his  head,  the  result  of  a  blow 
received  two  months  previously.  On  examining  the  wound,  in  the 
centre  of  an  ulcer,  located  about  the  position  of  the  left  middle  parie- 
tal lobe,  was  found  the  broken  edge  of  a  knife-blade.  On  being  told 
of  this  he  seemed  thoroughly  surprised.  But  little  could  be  made  out 
as  regards  the  incidents  of  the  attack,  except  that  a  man  had  struck  him 
on  the  top  of  the  head  so  forcibly  that  he  had  fallen  on  his  hands  and 
knees,  but  had  recovered  himself  almost  immediately.  He  said  that 
he  did  not,  at  that  time,  or  afterwards,  lose  consciousness,  nor  had  he 
had  even  a  headache.  All  symptoms  of  brain  injury  were  absent. 
He  did  not  complain  of  any  pain  or  uncomfortable  sensation  when  the 
knife-blade  was  removed,  but  in  the  afternoon  of  the  same  day  he  had 
slight  pains  in  the  head.  March  7th,  had  slept  well.  No  headache, 
temperature  100°.  Slight  retinal  hypersemia.  March  8th,  epilepti- 
form seizures  set  in  to-day,  beginning  with  twitching  of  the  right  arm, 
but  soon  becoming  general.  Prof.  Nancrede  trephined  over  the  seat 
of  injury,  the  bone  removed  showing  a  slight  depression  of  the  inner 
table.     The  position  which  the  blade  had  occupied  could  be  seen  in 

*  Lemons  Orales  de  Clin.  Chirurg.,  2d  ed.,  vol.  vi.  p.  146. 
f  Intern.  Encycl.  of  Surg ,  vol.  v.  p.  S3. 


TREPHINING    IN    FRACTURED   SKULL.  163 

the  dura  mater,  there  being  an  opening  surrounded  with  dense  cica- 
tricial tissue.  The  dura  mater  did  not  seem  to  be  congested,  and  there 
Avas  evidently  no  pus  or  fluid  beneath  it.  During  the  next  three 
weeks  the  fits  apparently  ceased,  but  symptoms  indicating  cerebral 
abscess — viz.,  temperature  often  low,  97j°-98°,  slow  pulse,  marked 
mental  dulness — set  in.  March  30th,  temperature  99°,  pulse  70°, 
The  patient  was  unconscious,  with  right-sided  hemiplegia,  and  rapidly 
sinking.  Prof.  Nancrede,  on  reflecting  the  flap  covering  the  trephine 
hole,  found  it  filled  by  the  tensely  stretched  dura  mater,  pulsating 
strongly.  A  small  incision  was  made  through  this,  but  nothing  was 
evacuated.  The  coma  rapidly  deepening,  an  aspirator  needle,  con- 
nected with  a  vacuum,  was  passed  in  at  three  or  four  different  spots, 
to  the  depth  of  f  inch,  but  with  no  result.  Feeling  convinced  that 
pus  was  ])resent,  and  from  the  symptoms  that  it  was  compressing  the 
ascending  frontal  and  parietal  convolutions,  Prof  Nancrede  proceeded 
to  set  a  large-crowned  trephine  in  front  of  and  below  the  first  open- 
ing, which  was  slightly  behind  tlie  fissure  of  Rolando.  Before  the 
skull  was  half  divided  both  pulse  and  respiration  ceased.  The  opera- 
tion being  rapidly  completed,  the  dura  mater  was  incised  without  re- 
sult. At  this  moment  a  large  drop  of  pus  oozed  up  through  one  of 
the  aspirator  punctures.  A  knife  being  plunged  into  the  brain  sub- 
stance, from  one  to  two  ounces  of  pus  were  evacuated.  The  patient 
appeared  to  be  quite  dead,  but  vigorous  and  prolonged  artificial  res- 
piration revived  him.  The  next  day  a  hernia  cerebri  as  large  as  a 
walnut  was  protruding  from  the  wound  in  the  dura  mater.  This  in- 
creased in  size,  and  broke  down,  the  patient  dying  on  April  4th.  At. 
the  autopsy  the  left  parietal  lobe  formed  an  enormous  abscess  cavity, 
the  abscess  being  superficial,  and  destroying  the  greater  portion  of  the 
upper  part  of  the  left  hemisphere. 

TREPHINING*  IN  FRACTURED  SKULL, 

(Figs.  41  and  42.) 

The  scalp  having  been  shaved  and  thoroughly  cleansed  (infra), 
the  patient  brought  under  the  influence  of  chloroform,t  unless  a  con- 

*  It  has  been  already  stated  tliat  in  many  cases  of  depressed  fractures,  after  exposure 
of  the  fragments,  a  pair  of  diessing-forceps  and  an  elevator  may  do  all  that  is  required. 
That  the  trephine  itself  is  not  always  needed  should  be  clearly  understood,  as  it  is 
probable  that  elevation  of  fragments  might  most  wisely  have  often  been  performed  if  it 
had  not  been  for  the  absence  of  a  special  instrument,  wrongly  supposed  to  have  been 
essential,  or  for  the  dread  of  an  operation  of  undoubted  severity  with  its  necessary 
laceration  of  the  vascular  diploe,  and  requiring  delicacy  and  skill  also. 

f  I  much  prefer  this  angesthetic,  if  possible,  in  these  cases  of  trephining,  on  account 
of  the  greater  excitement  and  congestion  which  are  usually  associated  with  ether.  But 
whenever  it  is  possible,  and  especially  when  the  pulse  and  breathing  are  failing,  anaes- 
thetics should  be  dispensed  with  (p.  154), 


164 


OPERATIONS    ON    THE    HEAD    AND    NECK. 


dition  of  unconsciousness  renders  tliis  unnecessary,  the  head  is  sup- 
ported on  sand-bags  at  a  convenient  height.  The  fracture  is  next 
exj^osed  by  appropriate  flaps,  the  old-fashioned  crucial  or  T-shaped 
incisions  being  as  useful  as  any,  or  a  semilunar  incision  which  can 
afterwards  be  converted  into  a  Y,  if  it  be  needful  to  follow  a  line  of 
fracture.*  The  incisions  should  usually  go  down  to  the  bone  itself, 
and  the  pericranium  should  be  raised,  by  the  handle  of  the  scalpel, 
cleanly  and  regularly  off  the  bone,  together  with  tlie  flaps.  If  it  be 
needful  to  operate  through  the  temporal  muscle,  its  fibres  must  be  suffi- 
ciently severed  and  raised  with  the  flaps,  it  being  somewhat  more 
difficult  to  separate  the  periosteum  here,  on  account  of  its  thinness  in 
this  region,  and  more  intimate  adhesion  to  the  subjacent  bones. f  In 
reflecting  scalp-flaps,  free  hasmorrhage  is  nearly  always  met  with,  espe- 

FiG.  41. 


Compound  depressed  fracture  of  gutter  form.    There  being  no  comminution,  the  trephine  has 
been  placed  close  to,  and,  in  part,  overhangs  the  fracture  (Hutchinson). 


cially  in  the  case  of  the  chief  superficial  trunks  and  the  deep  temporal 
arteries,  but  this  is  promptly  and  easily  arrested  by  the  use  of  Spen- 
cer Wells's  forceps,  which  act  as  most  useful  retractors,  taking  up  but 
little  room,  while  at  the  same  time  they  arrest  the  hemorrhage.  If 
bleeding  continues  from  any  crack  in  the  bone  which  may  now  be 
found,  it  Avill  only  cease  on  the  elevation  of  the  fragment,  or  on  the 
exposure  of,  and  the  dealing  with,  any  subjacent  clot.  The  fracture 
being  now  in  view,  and  it  being  found  impossible  to  introduce  an  ele- 

*  On  this  subject,  see  the  plan  adopted  by  Prof.  Horsley  (infra). 
f  The  greater  thickness  of  the  soft  i)arts  wiiich  will  here  form  the  cicatrix  will,  in  a 
measure,  make  up  for  the  difficulty  in  preserving  the  periosteum. 


teephi:ning  in  feactui^ed  skull. 


165 


vator  or  pair  of  dressing-forceps,  even  after  sawing  off  any  projecting 
angle  of  bone,  the  surgeon  must  decide  where  to  place  his  trephine. 
In  doing  so,  he  must  choose  a  spot,  if  possible,  clear  of  a  sinus,  or 
large  branch  of  the  middle  meningeal  artery,*  and  one  which  will  at 
the  same  time  support  firmly  the  pressure  needed  in  the  working  of 
the  trephine.  Thus  the  pin  and  the  greater  part  of  the  trephine  crown 
are  placed  on  sound  bone  (Fig.  41),  while  a  small  part  of  the  trephine 

Fig.  42. 


'^^       f, 

J- 1 


If|ff*fe 


Severe  compound  fracture  of  skull.  The  bone  being  much  damaged  by  comminution,  the  tre- 
phine has  been  placed  at  a  little  distance  from  the  fracture,  so  as  to  be  on  sound  skull.  The 
intervening  bone  would  be  readily  clipped  away  with  bone  forceps.  The  flaps  are  retracted, 
and  cut  vessels  in  them  at  the  same  time  cominanded  by  three  pairs  of  torsion-forceps. 

usually  overhangs  a  depressed  fragment.  But  if  the  surgeon  fears 
that  the  fragments  are  in  contact  with  the  dura  mater,  and  perhaps 
injuring  it,  and  that  the  jarring  movement  of  the  trephine  coming  in 
contact  with  one  may  be  pernicious,  he  will  so  place  his  trephine  that 
it  rests  entirely  on  sound  bone,  any  intervening  bridge  being  easily 
cut  away  (Fig.  42).  A  spot  being  thus  chosen,  a  trephine  of  appropri- 
ate size  is  taken,t  with  the  centre-pin  protruded  for  about  a  tenth  of 

*  If  it  is  really  needful  to  trephine  over  one  of  these  vessels,  the  remnrks  at  pp.  159, 
178,  will  show  how  the  hpemorrhage  should  be  met. 

t  One  f  inch  in  diameter  is  iisnally  ample.  The  conical  trephine  is  said  by  Ameri- 
can surgeons  [e.g.,  Nancrede,  he.  supra  cit.  p.  96;  Dr.  Hopkins,  Ann.  of  Surg.,  vol.  ii. 
No.  7,  p.  69)  to  be  safer  than  the  ordinary  one,  it  being  almost  impossible,  owing  to  its 
greater  steadiness,  to  injure  the  brain  with  it,  if,  as  the  deeper  part  of  the  internal  table 


1G6  OPERATIONS    ON    THE    HEAD    AND    NECK. 

an  inch,  and  firmly  fixed  in  this  position,  the  trephine  being  so 
grasped  in  the  hand,  that  the  index  finger  steadies  the  centre-pin 
screw  when  the  hone  is  entered.  The  instrument  is  now  firmly  ap- 
plied to  the  bone,  the  centre-pin  being  bored  inwards,  and  as  soon  as 
the  teeth  feel  the  bone,  the  trephine  is  worked  from  left  to  right  and 
then  from  right  to  left,  care  being  taken  to  exert  equal  pressure  in 
both  directions  ;  while  the  first  groove  is  being  cut,  the  movements  of 
the  trephine  must  be  light  and  quick,  but  without  jerking,  the  ten- 
dency of  the  instrument  to  slip  being  met  with  steady  bearing  on  the 
centre-pin,  and  by  keeping  the  left  forefinger  at  first  on  the  bone,  close 
to  the  trephine. 

As  soon  as  a  groove  has  been  cut  sufficient  to  keep  the  trephine 
steady,  the  pin  is  drawn  upwards,  and  so  fixed.  The  rotary  move- 
ments alternating  from  side  to  side  are  now  continued,  care  being 
taken  to  bear  as  evenly  as  possible  on  every  part  of  the  circle,  till  the 
diploe*  (if  tliis  be  present)  is  reached.  This  is  known  by  the  easier 
working  of  the  insti'ument,  and  by  the  softer  sound.  On  the  living 
body  at  least,  owing  to  the  oozing  from  the  vascular  parts  around,  the 
blood-staining  of  the  bone-dust  described  as  taking  place  at  this  stage 
is  liable  to  be  fallacious. 

Throughout  the  operation,  but  especially  now  as  the  thinner  table 
is  being  reached,  every  care  must  be  taken  to  keep  the  circle  of  equal 

depth — (1)  by  pressing  on  the  saw  evenly ; 
(2)  by  making  it  bite  in  as  equally  from 
right  to  left  as  from  left  to  right;  (3)  by  re- 
membering that,  owing  to  the  skull  being 
spheroidal  in  shape,  it  is  impossible,  with- 
out the  greatest  carefulness,  to  keep  the 
groove  of  equal  depth  all  round ;  (4)  by 
liearing  in  mind  that  M'hile  the  average 
thickness  of  the  adult  skull  is  one-fifth  of 
an  inch,  the  thickness  varies  so  much  that  it  is  almost  always  greater 
at  one  part  of  a  trephine-circle  than  another  f  (Fig.  43).     Thus  at  fre- 

is  divided,  any  undue  pressnre  sliould  be  made.  But  if  nsed  witli  ordinary  skill,  the 
old  form  of  trephine  is  perfectly  safe.  The  modified  burr  of  the  dental  engine  has 
been  fonnd  to  work  accurately  by  some  American  surgeons— e.gr.,  Dr.  Roberts  {loc. 
snpra  cit.),  especially  in  removing  large  areas  of  bone.  Hitherto,  simi)ler,  old-fash- 
ioned instruments  have  held  their  place  in  England. 

*  This  is  absent  in  early  life  and  in  the  aged.  Again,  over  a  large  part  of  the 
squamous  bone  and  in  the  occipital  fossse,  diploe  is  never  met  witii.  Thus,  in  cases 
where  the  diploe  is  absent,  especially  in  the  thinned  calvaria  of  an  aged  corpse,  it  is 
quite  possible,  by  using  haste  or  force,  to  jam  the  crown  of  bone  in  upon  the  brain. 

t  Mr.  Holden's  words  (Landmarks,  p.  5)  are  excellent:  "In  applying  the  treiihine 
this  is  not  a  bad  rule-- 'Tiiiuk  that  you  are  operating  on  the  thinnest  skull  ever  seen, 
and  thinner  in  one-half  of  the  circle  than  in  the  other.'"     Sir  A.  Cooper  (Sur(jery, 


TREPHINING    IX    FRACTURED    SKUI.L.  167 

quent  intervals  the  flat  end  of  a  trephine-probe,  or  a  clean  quill  cut 
pointed  must  be  carefully  introduced  at  different  spots,  and  when 
the  circle  is  found  to  be  deeper  on  one  side  (still  more  if  it  is  perfo- 
rated) the  trephine  must  be  so  slanted  that  its  teeth  are  only  cutting  on 
that  part  of  the  groove  which  is  still  shallow.  When  the  groove  has 
been  made  sufficiently  deep,  and  careful  examination  finds  one  or 
two  points  of  penetration,  the  bone  may  be  removed  either  by  tilting 
it  out  in  the  trephine,  by  sharply  rocking  this  from  side  to  side,  or  by 
inserting  the  elevator  at  the  deepest  part  of  the  groove  and  lifting  up 
the  disk  of  bone  by  carefully  making  a  fulcrum  of  the  sound  bone  or 
of  a  finger. 

If  profuse  haemorrhage  occur  on  raising  either  the  disk  of  bone  or  a 
depressed  fragment,  it  will  probably  come  either  from  a  branch  of  the 
middle  meningeal  artery  or  from  a  sinus.  The  treatment  of  the  former 
is  given  at  p.  178 ;  in  the  latter  case  pressure  should  be  at  once  applied 
by  means  of  a  piece  of  sponge  which  has  been  kept  in  and  wrung  out 
of  a  solution  of  carbolic  acid,  or  mercury  perchloride,  and  dusted 
with  iodoform  powder ;  if  this  has  to  be  tucked  under  an  edge  of 
bone  to  control  the  bleeding,  a  ligature  of  carbolized  silk  should  be 
fastened  on  to  it,  to  secure  its  withdrawal  in  about  three  days'  time 
(p.  159). 

In  the  case  of  a  punctured  fracture,  a  full-sized  inch  trephine  should 
be  applied,  so  as  to  remove  the  outer  table  around  the  immediate 
neighborhood  of  the  puncture,  and  thus  expose  freely  the  damage  to 
the  inner  table. 

If  after  removing  a  crown  of  bone  more  room  is  still  required,  this 
may  be  obtained  either  by  taking  out  a  second  croAvn  close  by  and 
joining  the  two,  or  by  the  use  of  a  Hey's  saw  or  Hoffman's  forceps; 
with  the  latter  instrument,  if  of  reliable  temper,  a  considerable  area 
of  bone  can  be  quickly  nibbled  away. 

Mr.  Hutchinson*  has  drawn  attention  to  the  feasil)ility  of  obtaining 
satisfactory  access  to  depressed  fragments,  and  of  removing  them, 
after  trephining  through  the  external  table  only.  Thus,  at  p.  188,  loc. 
infra  cit.,  he  writes :  "  With  a  small  trephine  I  removed  a  circle  of  the 
bone  in  front  of  the  depression,  not  going  deeper  than  just  into  the 
diploe.  This  done,  with  a  little  trouble  I  got  away  the  anterior  frag- 
ment, which  acted  as  a  buttress  between  the  depressed  fragments  and 
the  other  part,  and  would  have  entirely  prevented  its  being  elevated. 

edited  l)y  Dr.  A.  i,ee,  vol.  i.  p.  1S8)  thus  speaks  of  the  operation.     "Some  people  say 
that  this  is  a  trifling  operation,  not  difBcnlt  to  perform,  nor  dangerous;    but  they 
deceive  you  :  it  is  one  of  the  most  dangerous  operations  in  surgery ;  whilst  performing 
it  there  is  but  a  single  step — a  small  network — between  your  patient  and  eternity." 
*  Clin.  Sur(/.,  vol.  i.  p.  187  et  seq. 


168  OPERATIONS    ON    THE    HEAD    AND    NECK. 

When  this  was  removed,  I  easily  got  the  point  of  an  elevator  into  the 
diploe  of  the  depressed  portion,  and  succeeded  in  lifting  it  into  place." 

With  all  due  deference  to  Mr.  Hutchinson,  I  cannot  think  that  this 
method  of  only  removing  the  outer  table  should  be  generally  adopted, 
and  for  these  reasons.  In  hands  less  experienced  levering  up  a 
depressed  fragment  by  insinuating  the  point  of  an  elevator  into  its 
diploe,  seems  to  be  very  likely  to  end  in  increasing  the  depression. 
Again,  every  surgeon  in  whose  hands  the  outer  table  has  come  away, 
accidentally,  by  itself,  knows  how  difficult  this  renders  the  completion 
of  the  operation.  A  surgeon,  then,  who  had  done  this  purposely,  and 
then  found  himself  unable  to  remove  the  depressed  fragments  by  the 
method  just  given,  would  very  likely  find  the  completion  of  the  tre- 
phining and  the  getting  out  of  the  inner  table  a  matter  of  embarrassing 
difficulty. 

Mr.  West  recommends  that  the  periosteum,  which  has  been  care- 
fully preserved,  should  be  adjusted  by  catgut  sutures,  this  precaution 
tending  to  prevent  any  subsequent  hernia  cerebri.  Sufficient  drainage 
must  of  course  be  provided. 

With  the  same  view,  in  order  to  diminish  the  subsequent  gap,  any 
detached  fragments  of  bone  (which  should  have  been  kept  in  warm 
carbolic  acid  solution)  may  be  placed  across  the  aperture  in  the  skull, 
it  having  been  found  by  Dr.  Macewen*  that  they  will  adhere  and  give 
no  further  trouble.  Sufficient  drainage  is  then  provided  by  fine  tubes 
or  drains  of  horsehair  or  gut,  sutures  inserted  and  dressings  applied. 

The  terse  summing  up  of  Dr.  Amidon,  of  New  York,t  may  here  be 
quoted :    "  Let  the  operation  always  be  done  with  antiseptic  precau- 

*  On  this  subject  I  would  refer  the  reader  to  a  case  of  Dr.  Macewen's  (p.  102).  Mr. 
Clark  (Lancet,  1886,  vol.  i.  p.  243)  in  a  case  of  trephining  for  traumatic  epilepsy,  in 
which  this  operation  was  followed  by  much  imjirovenient,  but  not  a  complete  cure, 
replaced  the  crrtwn  of  bone — a  piece  of  the  frontal,  and  the  seat  of  ostitis — after 
bevelling  off  the  inner  edge  so  as  to  prevent  pressure  upon  the  dura  mater,  and 
after  cutting  a  notch  in  the  side  of  it  to  serve  for  drainage.  The  restored  crown 
did  not  necrose  but  united  satisfactorily.  However  right  it  may  be  to  replace,  in  most 
cases,  bone  which  has  been  removed,  especially  in  tiiose  cases  wiiere  the  removal  has 
been  extensive,  I  doubt  very  much  if  this  course  is  judicious  in  cases  of  trephining  for 
traumatic  epilepsy.  Until  this  subject  has  been  more  thoroughly  worked  out,  I 
think  it  would  be  wiser  to  leave  the  small  trepliine-gap  not  filled  up,  and  thus  provide 
a  safety-valve  for  the  relief  of  varying  tension.  This  course  would  be  especially  indi- 
cated in  cases  of  long-standing  depressed  fracture  where  trephining  is  resorted  to  late, 
and  though  the  source  of  irritation  is  thus  renewed,  the  brain  has  taken  an  impression, 
which,  though  perhaps  latent,  will  remain  permanent,  and  which  will  be  prone  to  show 
itself  on  very  slight  excitement.     See  foot-note  f,  p.  157. 

.  t  Med.  News,  Philadelphia,  June  21st,  1884;  Ann.  nf  Surg.,  No  3,  vol.  i.  To  this 
second  paper  of  Dr.  Amidon,  a  very  instructive  and  helpful  statistical  table  of  115 
cases  is  appended. 


PUS    BETWEEN'    THE    SKULL    AND    DURA    MATER.  169 

tions.  Try  and  secure  only  proximate  coaptation  of  the  flaps.  Pro- 
vide the  freest  possible  drainage.  Use  cold  antiseptic  dressings, 
without  much  compression.  Enjoin  the  strictest  quiet  in  a  posture 
facilitating  drainage." 

TREPHINING  FOR  PUS  BETWEEN  THE   SKULL  AND 

DURA  MATER. 

While  the  mode  of  using  the  trephine  here  will  in  no  way  differ 
from  that  already  given,  a  few  practical  remarks  will  be  made  on  this 
most  important  condition. 

It  is  well  known  that  operative  interference  here  is  now  less  frequent 
than  it  would  appear  to  have  been  a  hundred  years  ago  when  Mr.  Pott 
drew  the  attention  of  surgeons  to  the  need  of  trephining  when  pus  was 
present  immediately  beneath  the  skull.  For  while  Mr.  Pott,  in  liis  day, 
saved  five  out  of  eight  of  these  cases  in  which  he  trephined,  surgeons 
of  the  present  time,  when  they  trej^hine,  have  been  usually  baffled  by 
the  coexistence  of  pyemia,  or,  if  this  ominous  complication  be  absent, 
by  finding  the  collection  of  pus  not  localized  between  the  bone  and 
dura  mater,  or  if  so  localized,  combined  with  suppurative  arachnitis 
also. 

Mr.  Holmes  (Treat,  on  Surf/.,  1st  ed.  p.  130)  brings  forward  the  fol- 
lowing weighty  statements:  "Some  years  ago  I  ])ublished*  the  expe- 
rience of  St.  George's  Hospital  in  this  particular  for  seventeen  years — 
1841  to  1857  inclusive.  Eight  cases  occurred  in  which  the  trephine 
was  applied  for  pus.  The  pus  Avas  found  in  every  case,  but  all  the 
patients  died.  Seven  were  examined  after  death,  and  in  six  of  these 
unmistakable  evidence  of  phlebitis  in  the  sinuses  of  the  brain  and 
veins  of  the  skull  and  of  general  pj'semia  was  discovered.  In  the 
seventh  case  the  abscess  reached  the  ventricles  of  the  brain.  There 
Avere  eight  other  cases  in  which  the  trephine  was  not  used,  and  where 
matter  was  found  above  the  dura  mater,  but  it  Avas  not  limited  to  this 
situation  in  any  of  these  cases,  nor  would  adequate  exit  have  been 
procured  for  it  by  the  trephine.  In  nine  other  cases  there  had  been 
intra-cranial  suppuration,  but  the  matter  was  diffused  among  the 
membranes  or  in  the  substance  of  the  brain,  and  lay  entirely  below 
tbe  dura  mater." 

The  above  most  gloomy  picture  of  what  has  been  usually  met  with, 
only  serves,  I  think,  to  contirm  the  opinion  given  below  that  these 
cases  should  be  explored  early,  being  treated,  in  short,  more  like  cases 
of  acute  periostitis  and  osteo-myelitis  elscAvhere,  than  has  hitherto 
been  the  case. 

When  it  is  remembered  that  pus  does  not  form  between  the  bone 

*  Brit.  Med.  Journ.,  October  16th,  1858. 


170  OPERATIONS  ON  THE  HEAD  AND  NECK. 

and  dura  muter  without  a  ])revious  sta,a;e  of  traumatic  ostitis  and 
plilelntis  of  the  veins  of  the  diploe,  it  will  be  readily  understood  how 
easily,  if  the  wound  be  foul,  septic  osteo-myelitis  and  septic  phlebitis, 
with  the  inevitable  result  of  pya^nia,  will  follow. 

Indications  of  the  Formation  of  Pus  between  the  Bone 
and  Dura  Mater:  Question  of  Trephining.— History  of  a  head 
injury  with  damage  of  some  kind  to  the  outer  table.  Thus  there  is 
often  a  scalp  wound  exposing  the  pericranium,  often  opening  this  up 
at  one  or  two  jDoints,  perhaps  small  and  not  seen  at  the  time ;  occa- 
sionally the  bone  itself  is  laid  bare  by  the  injury.  Either  now  or  later 
on  the  wound  becomes  septic.  After  a  varying  period,  usually  in  the 
course  of  the  second  week  after  the  injury  (during  which  period  defi- 
nite symptoms  are  often  absent),  headache,  fretfulness,  nausea,  or 
vomiting  set  in,  gradually  followed  by  drowsiness,  delirium,  twitch- 
ings,  convulsions,  paralysis,  coma,  and  death. 

This  on-rush  of  symptoms  al)out  the  eighth  or  tenth  day  may  be 
accompanied  by  evidence  of  pysemia — viz.,  rigors  followed  by  sweating, 
a  jactitating  temperature,  progressive  emaciation,  and  afi'ections  of 
viscera  and  joint?,  amongst  which  pleuro-pneumonia  is  one  of  the 
most  frequent  and  grave. 

The  surgeon  who  is  watching  a  case  of  this  kind,  and  also  is  not 
unmindful  of  what  has  happened  and  what  is  liable  to  be  going  on — 
the  injury  to  the  pericranium  and  bone,  the  ostitis  and  osteo-myelitis 
with  plugging  of  the  diploic  veins,  the  extension  to  the  inner  table, 
the  formation  between  the  bone  and  dura  mater  of  lymph  ready  to 
suppurate,  this  deep-seated  inflammation  being  only  too  ready  to 
extend  to  the  arachnoid  and  thus  become  a  diffused  meningitis — will 
find  it  a  matter  of  much  difficulty  to  answer  the  question.  How  far 
has  the  mischief  gone?  Is  the  case  a  hopeless  one?  If  the  intra- 
cranial collection  of  pus  be  a  localized  one  and  uncomplicated,  well- 
marked  hemiplegia  and  the  absence  of  pya^mic  symjitoms  will  call 
hopefully  for  trephining.  On  the  other  hand,  paralysis,  indistinct  or 
complete,  epileptiform  convulsions,  extreme  irritability,  an  aspect  of 
fever,  and,  especially,  any  evidence  of  involvement  of  nerves  at  the 
base,  will  all  point  to  that  form  of  meningitis  which  will  show  itself 
as  a  diffuse  layer  of  pus  and  lymph  over  one  side  of  the  arachnoid. 

Equally  pointing  to  a  fatal  issue  Avill  be  the  symptoms  of  pysemia 
already  alluded  to,  and  needing  no  further  mention  here. 

What  is  to  he  done  in  these  cases?  Where  the  evidence  of  menin- 
gitis is  undoubted,  of  some  days'  standing,  where  the  hemii^legia  has 
been  little  marked,  or  where  it  is  replaced  by  paraplegia,  general  con- 
vulsions, and  other  unfavorable  signs,  no  surgeon  will  be  wise  in 
trephining. 

Should  evidence  of  coexisting  pyajmia  be  looked  upon  as  equally 


PUS  BETWEEN  THE  SKULL  AND  DURA.  MATER.       171 

hopeless  and  equally  negativing  the  use  of  the  trephine?  I  scarcely 
think  so.  Every  surgeon  knows  that,  although  pyaemia  is  usually 
fatal,  it,  very  occasionally,  ends  favoral)ly.  Again,  in  treating  pyaemia 
resulting,  from  periostitis  and  osteo-myelitis  elsewhere,  we  are  not 
deterred  from  making  free  incisions  and  exploring  the  bone. 

The  real  treatment  of  these  cases  must,  of  course,  be  really  pre- 
ventive— i.e.,  every  scalp  wound  should  be  rendered  aseptic  and  kept 
so  from  the  very  first,  however  slight  it  seems  to  be.  But,  as  this  pre- 
caution is  not  always  taken,  and  is  occasionally  impossible,  the  con- 
dition of  the  pericranium  and  bone  should  be  explored  earlier,  at  the 
very  first  warning  of  danger.  Instead  of  treating  such  a  case  as  a 
special  result  of  head  injury,  and  waiting  for  evidence  of  pus  between 
the  bone  and  dura  mater,  we  should,  I  think,  deal  with  it  as  we  do 
periostitis  and  ostitis  elsewhere;  that  is  to  say,  that,  in  cases  of  this 
kind  where  there  is  reason  to  believe  that  the  bone  has  been  injured, 
especially  if  there  is  any  doubt  as  to  the  condition  of  the  wound 
throughout,  the  surgeon  should,  on  the  first  appearance  of  malaise, 
irritability,  headache,  nausea,  chilliness,  explore  the  wound.  Any 
granulations  here  present  will  very  likely  be  at  a  standstill.  A  piece 
of  bone  will  probably  be  bare  and  perhaps  soft,  the  pericranium  infil- 
trated and  separating.  The  whole  area  of  bone  which  is  thus  being 
deprived  of  its  pericranium  should  be  explored,  and  drainage  pro- 
vided. But  in  nearly  all  cases,  especially  if  the  bone  is  softened  at  all, 
it  will  be  wiser  to  do  more,  and  open  the  bone  with  a  trephine  to  give 
vent  to  any  inflammatory  material  in  the  diploe,  to  prevent  septic 
phlebitis  and  its  extension  to  the  sinuses,  and  to  save  the  inflammation 
from  reaching  the  inner  table  and  dura  mater. 

The  above  depends  on  the  fixed  conviction  that  trephining,  in 
careful  hands,  and  with  due  precautions,  is  not.  in  itself,  a  dangerous 
operation  (p.  156),  and  on  the  fact,  which  is  beyond  dispute,  that,  if 
these  cases  are  left  till  hemiplegia  pronounces  the  existence  of  intra- 
cranial pus,  they  will,  too  often,  be  left  too  long,  as  this  waiting  will 
give  time  for  the  onset  of  pysemic  infection,  and  for  the  arachnoid  to 
be  involved  in  the  inflammation. 

The  operation  of  trephining  here  will  in  no  way  differ  from  that 
already  described.  Pus  welling  up  from  the  diploic  cancelli,  or  a.  fetid 
condition  of  these,  is  ominously  suggestive  of  impending  pytemia.  If 
such  a  condition  be  present,  the  bone  should  be  freely  removed,  and 
disinfected  as  far  as  possible ;  but,  from  the  probable  extension  of 
thronibi  to  the  sinuses,  the  outlook  is  a  very  dark  one.  If  pus  be 
present  between  the  bone  and  dura  mater,  it  must  be  thoroughly 
evacuated,  and  free  drainage  provided.*     The  condition  of  the  dura 

*  III  these  case?,  nnd,  in  fact,  in  any  trephining  cases  where  the  discharges  are  foul 
and  tiie  scalp  tlie  seat  of  cellulitis  or  erysipelas,  iced  boracic  acid  (a  saturated  solution) 


172  OPERATIONS   ON    THE    HEAD    AND    NECK. 

mater  should  always  be  examined  into,  whether  pus  is  found  super- 
ficial to  it  or  no.  If  it  pulsate  freely  and  be  natural  in  appearance 
and  devoid  of  lymj)h,  nothing:  more  need  be  done.  If,  on  the  other 
hand,  it  bulge  into  the  trephine-hole  devoid  of  pulsation,  it  should  be 
punctured,  this  perhaps  giving  vent  to  a  jet  of  purulent  fluid  from  the 
arachnoid  cavity.  If  the  arachnoid  is  seen  to  be  covered  with  lymph, 
this  is  of  the  gravest  omen.  The  possibility  of  the  existence  of  cere- 
bral abscess  must  always  be  remembered  in  these  cases,  where  nothing 
else  has  been  found  to  account  for  tlie  head  symptoms.  The  symptoms 
and  treatment  are  fully  given  at  p.  183. 

The  following  cases  are  good  examples  of  this  most  dangerous  con- 
dition of  ostitis  of  the  cranium  and  its  sc(j[ue]?e  and  complications: 

The  first  case,  reported  by  Mr.  Hutchinson,*  show^  pya:'mia  promi- 
nent rather  than  arachnitis  ;  the  second,!  also  Mr.  Hutchinson's,  shows 
the  reverse  condition — much  arachnitis  and  no  general  pyiemic  infec- 
tion. The  third,  one  under  my  own  care,  shows  both  arachnitis  and 
pycemia  combined.  In  all  pus  was  present  between  the  bone  and 
dura  mater. 

J.  W.,  aged  ten,  on  October  15th  received  a  large  lacerated  scalp 
wound  from  a  dog  bite,  a  triangular  flap  of  all  the  tissues  of  the  scalp 
being  torn  up,  from  the  left  parietal  bone.  The  pericranium  was  not 
torn  up  excepting  perhaps  at  a  few  points. 

The  boy  was  admitted  into  the  London  Hospital  at  once,  the  flap 
of  skin  adjusted,  and  for  some  time  all  went  on  perfectly  well,  the  boy 
being  only  kept  in  bed  for  a  day  or  two. 

Oct.  28.  He  did  not  eat  his  dinner  as  well  as  usujd.  The  wound 
was  looking  a  little  pale. 

Oct.  29.  While  up  and  at  dinner  he  was  noticed  to  be  cold  and 
shivery.  A  very  severe  rigor  followed.  It  was  impossible  to  ascertain 
whether  he  had  headache  for  some  days  or  not.  In  the  wound  the 
granulations  were  pale  and  glassy,  and  a  small  piece  of  dry,  bare  bone 
was  exposed. 

During  the  next  few  days  there  were  repeated  rigors  and  much 
headache. 

Nov.  1.  He  had  now  very  decidedly  the  aspect  of  pneumonia,  and 
the  breathing,  temperature,  pulse,  and  cough  confirmed  this. 

Nov.  2.  He  seemed  better  than  yesterday,  the  respiration  being 
more  easy.  There  is  not  the  slightest  sound  of  paralytic  weakness. 
Doubts  have  been  expressed  as  to  whether  this  lioy  is  or  is  not  the 
subject  of  pyaemia.     He  looks  comfortable,  excepting  for  the  blueness 

lotion  applied  by  means  of  lint  frequently  welted  and  renewed,  together  with  a  dust- 
ing of  iodoform,  is  preferable  to  dry  dressings  ciianged  less  frequently. 

*  Clin.  Surg.,  vol.  i.  p.  97. 

■\  Loc.  supra  cit.,  p.  102. 


PUS    BETWEEN    THE   SKULL    AND    DURA    MATER.  173 

of  the  lips,  which  is  less  than  yesterday.  That  he  is  suffering  from 
pneumonia  all  must  admit,  and  that  the  pneumonia  does  not  produce 
the  usual  train  of  symptoms  (no  rust-colored  sputum,  no  great  dys- 
pnoea, tongue  almost  clean,  etc.).  He  has  had  a  series  of  rigors  of  the 
most  marked  character.  If  tliere  had  been  but  a  single  rigor,  it  is 
very  possible  that  it  might  have  been  indicative  only  of  pneumonia, 
but  tiieir  recurrence  seems  to  me  to  denote  pya?mia.  This  diagnosis 
is  also  favored  by  the  fact  of  his  apparent  improvement  at  times  and 
great  variations  in  condition. 

The  wound  was  noAV  secreting  a  very  fair  quantity  of  healthy  pus. 
Its  granulations  are  much  better  than  they  were,  and  fairly  florid. 

During  the  next  three  days  the  thoracic  symptoms  increased.  He 
emaciated  rapidly.  Consciousness  was  perfect  to  the  last,  and  he  had 
neither  paralysis  nor  convulsions.  All  traces  of  granulations  dis- 
appeared from  the  wound.     He  died  November  7. 

There  were  very  numerous  pya?mic  deposits  in  the  lungs,  liver,  and 
spleen.  Beneath  the  scalp  wound  was  bare  and  greenish  l)one  the 
size  of  a  crown-piece.  The  edges  of  the  wound  were  thin  and  loose, 
and  the  pericranium  was  also  loose  over  a  surface  as  large  as  the  palm 
of  the  hand,  comprising,  in  fact,  nearly  all  the  parietal  bone.  There 
was  a  recent  sear  in  the  scalp,  crossing  the  vertex  transversely,  just 
above  the  lambdoid  suture;  the  pericranium  here  was  thickened  and 
inflamed,  and  the  bone  on  both  sides  of  the  sagittal  suture  here  was 
green.  On  applying  the  trephine  at  this  spot,  dirty-green,  fetid 
pus  was  exuded  on  the  inner  surface  of  the  bone.  It  must  be  observed 
that  this  portion  of  inflamed  bone  extended  on  each  side  of  the  sagittal 
suture,  and  that  it  was  under,  not  an  open  wound,  but  a  soundly 
healed  one. 

E.  S.,  aged  ten,  was  admitted,  July  21,  into  the  London  Hospital 
with  ver}^  extensive  laceration  of  the  scalp  on  the  left  side,  laying 
bare  the  parietal  bone.  During  the  first  few  days  he  took  his  food, 
was  perfectly  conscious,  and  seemed  to  be  doing  well. 

July  26.  Bone  as  large  as  a  crown-piece  is  exposed,  white  and  dry, 
above  the  left  ear. 

July  29.  A  strong  rigor. 

July  30.  Wound  without  granulations,  looking  glazed. 

July  31.  Very  restless.  Uses  all  his  limbs  at  times,  but  the  left 
ones  much  l)etter  than  the  right. 

Aug.  1.  The  skull  was  trephined  in  the  middle  of  the  exposed 
bone  two  inches  directly  above  the  left  ear.  The  dura  mater  was 
covered  with  yellow  lymph.  It  pulsated  pretty  freely.  On  cutting 
through  it,  about  a  drachm  of  thin,  purulent  fluid  jetted  out.  The 
visceral  arachnoid  was  seen  to  be  covered  with  lymph. 

Aug.  2.  He  still  uses  his  left  arm,  but  never  his  right  hand.  When 
the  brain,  which  bulged,  pulsating,  into  the  wound  was  pressed  baek,, 


174  OPERATIONS    ON   THE    HEAD    AND    NECK. 

thin  pus  ran  out  in  considerable  quantity  from  the  arachnoid  cavity. 
His  aspect  was  that  of  a  patient  in  tlic  very  last  stage  of  fever.  Death 
took  place  on  August  3. 

The  bone  around  the  trephine-aperture  was  dry  and  green.  Every- 
where on  the  left  side  the  parietal  arachnoid  was  concealed  by  a  thick 
deposit  of  puro-lymph,  whilst  everywhere  on  the  right  side  the  mem- 
branes were  perfectly  free  from  deposit,  polished  and  glistening.  The 
superior  longitudinal  sinus  contained  puriform  fluid.  The  skull  at 
the  seat  of  injury  was  discolored  over  an  extent  almost  as  large  as  the 
palm  of  tlie  hand;  adjacent  to  it  were  other  patches,  greenish-yellow, 
opaque,  and  non-vascular.  There  were  no  pyemic  deposits  in  the 
lungs  or  in  the  viscera  of  the  abdomen. 

E.  S.,  aged  forty,  slipped  while  getting  off  an  omnibus,  January  22, 
1877,  and  was  admitted  into  Guy's  Hospital  under  Mr.  Howse's  care 
with  a  scalp  wound  four  inches  long  exposing  the  right  parietal  bone. 

Owing  to  some  oversight  the  wound  was  not  dressed  at  first  anti- 
septically,*  the  discharge  became  offensive,  and  erysipelas  of  the  scalp 
setting  in  she  was  transferred  to  my  care  on  February  1.  At  this  time 
almost  the  entire  right  parietal  bone  was  exposed,  owing  to  sloughing 
of  the  pericranium. 

Incisions  were  made  where  needful,  drainage  tubes  introduced,  and 
in  a  few  days  the  erysipelas  had  subsided,  and  the  wound  was  sweet. 

Feb.  11.  She  had  a  rigor  for  the  first  time. 

Feb.  13.  There  was  some  paralysis  of  tlie  left  side  of  the  face  and 
the  left  limbs.     The  temperature  was  104°. 

Feb.  15.  The  hemiplegia  becoming  more  marked,  I  trephined 
through  the  exposed  bone,  about  one  inch  above  the  right  }j;irietal 
eminence.     Pus  was  met  with  in  the  diploic  cancelli. 

On  removing  the  crown  of  bone  an  ounce  of  thick,  foul,  greenish 
pus  welled  up.  The  inner  surface  of  the  bone  was  very  rough,  the 
dura  mater  which  corresponded  to  it  being  covered  with  velvety 
granulations.  As  the  dura  mater  did  not  pulsate,  it  was  punctured, 
but  without  result. 

The  patient  became  more  conscious  after  the  operation,  but  soon 
lapsed  again  into  a  semi-comatose  state.  Convulsive  seizures  of  all 
the  limbs,  with  twitchings  of  both  sides  of  the  face,  then  set  in  and 
continued  till  the  patient's  death,  on  February  17. 

The  })arietal  bone  was  found  to  be  dying  for  a  considerable  area, 
the  diploe  being  green  and  offensive.  The  pus  seemed  all  removed 
from  the  dura  mater,  but  there  was  suppurative  arachnitis  over  the 
right  hemisphere,  reaching  up  to  the  falx  in  one  direction  and  the 
base  in  the  other,  Init  stopping  short  of  each.  There  were  numerous 
i^ytemic  abscesses  in  the  lungs  and  liver. 

*  A  precaution  on  vvliich  mv  collea;ifiie  liabittially  insists. 


MIDDLE    MENINGEAL    HAEMORRHAGE.  175 

TREPHINING  FOR    MIDDLE   MENINGEAL 
HEMORRHAGE.*     (Figs.  44,  45.) 

Indications. — When  a  patient,  after  receiving  an  injiuy  to  the 
head,  lias  sliown 'several  of  the  symptoms  given  below. 

It  is  noteworthy  that  the  injury  and  amount  of  violence  vary 
extremely.  While  most  frequently  serious,  as  in  falls  on  the  head, 
the  violence  may  be  extremeW  slight,  as  when  a  patient  slips  going 
downstairs  and  strikes  the  head  against  the  wall,  when  a  boy  receives 
a  blow  from  a  cricket-ball,  or  when  a  child  has  a  fall  of  2  feet  6  inches 
out  of  a  swing.  From  this  the  following  conclusions  follow  naturally  : 
(a)  That  in  the  cases  of  severer  violence,  laceration  or  contusion  of  the 
brain  are,  only  too  frequently,  complications;  (b)  where  the  violence 
has  been  slighter,  either  no  fracture  may  be  present,  or,  if  one  be 
present,  it  is  often  only  a  mere  fissure,  and  may  involve  the  internal 
table  only. 

i.  Interval  of  Consciousness  or  L  ciditi/. — This  interval  between  the 
stunning  effects  of  the  injury  or  concussion  and  the  onset  of  com- 
pression from  the  effused  blood  varies,  when  present,  in  length  from 
a  few  minutes  to  several  hours.  In  about  half  the  cases  it  is  well 
marked.  In  a  second  class  it  is  but  little  marked,  and  may  easily  be 
overlooked  altogether.  In  a  third  and  last  set  of  cases  this  interval 
is  never  present  at  all,  owing  to  (1)  The  presence  of  a  very  large  haem- 
orrhage producing  compression-symptoms;  (2)  Coexisting  depression 
of  bone;  (3)  Coexisting  injury  to  the  brain;  (4)  Drunkenness  of  the 
patient. 

ii.  Condition  of  the  Limbs  as  to  Hemiplegia,  Paralysis,  Rigidity,  etc. — 
Hemiplegia,  though  w^ell  marked  in  a  large  proportion  of  cases,  must 
not  be  looked  upon  as  essential,  and  middle  meningeal  hemorrhage 
must  not  be  overlooked  because  hemiplegia  is  absent,  ill-marked,  or 
replaced  by  some  other  condition  of  the  limbs.  At  least,  the  following 
seven  conditions  of  the  limbs  may  be  met  with  in  middle  meningeal 
haemorrhage. 

(a)  Hemiplegia  present  and  well  marked,  the  leg  or  arm,  and 
usually  both  when  taken  up  and  let  go,  dropping  like  those  of  a 
corpse.  This  condition  is  present  in  probably  one-tiiird  of  the  cases. 
It  is  noteworthy  that  occasionally  the  hemiplegia  is  on  the  same  side 
as  that  injured,  the  extravasation  taking  place  on  the  side  opposite  to 
that  struck. 

(/5)  Hemiplegia  present,  but  little  marked.  In  these  cases,  which 
-are  not  uncommon,  the  extravasation  may  be  overlooked.  They  fall 
into  at  least  two  divisions.     In  one  the  hemiplegia  is  little  marked 

*  For  fuller  information  on  tliis  most  important  subject,  I  m;iy,  perhaps,  refer 
the  reader  to  an  article  contributed  to  the  Giujs  Hosp.  Reports,  1886,  p.  147. 


176  OPERATIONS    ON    THE    HEAD    AND    NECK. 

tlirougliout,  owing,  perhaps,  to  some  power  of  accommodation  on  the 
part  of  the  hrain,  or  to  the  oircuLation  remaining  feehle,  owing  to 
coexisting  shock  from  the  time  of  the  injury  to  the  moment  of  death. 

In  another  group  of  cases,  tlie  hemiplegia  is  ill  marked  hecause  of 
brief  duration,  coming  on  as  it  does  in  these  cases  towards  the  close, 
together  with  coma,  giving  but  little  warning  and  leaving  but  short 
time  for  interference. 

When  there  is  any  doubt  as  to  the  existence  or  degree  of  hemi- 
plegia, the  following  tests  should  be  carefully  made  use  of:  whether 
the  patient  resists  on  the  surgeon  attempting  to  move  the  limbs;  the 
power  of  the  grasp,  if  any;  the  result  of  pricking ;  whether  the  patient 
moves  either  of  his  hands,  or  which  of  them,  when  the  cornea  is  care- 
fully touched  or  the  cilia  gently  pulled. 

(y)  Hemiplegia  present,  but  temporary.  A  very  rare  condition, 
produced  probably  by  the  brain  being  able  to  accommodate  itself  to 
the  blood. 

(8)  Monoplegia,  or  the  paralysis  more  marked  in  one  limb  than  the 
•  other.  A  rare  condition,  as  the  haemorrhage  generally  makes  pressure 
upon  all  the  motor  area. 

(e)  General  paralysis.  Another  rare  condition,  the  existence  of 
which  may  l)e  explained  by  a  very  large  clot — e.g.,  on  the  left  side, 
rapidly  effused  and  making  pressure  through  the  left  side  of  the  brain, 
upon  the  right  as  well,  or  by  coexisting  extravasation  into  the  brain 
substance  itself. 

(C)  Absence  of  any  paralysis.  A  very  rare  condition,  and  one  which 
is,  perhaps,  due  to  the  blood  effused  from  the  middle  meningeal 
artery,  finding  its  way  through  a  fracture  in  the  skull,  beneath  the 
scalp. 

-(t])  Limbs  rigid,  convulsed,  or  twitching.  It  is  only  too  pro)?able 
here  that,  in  addition  to  middle  meningeal  extravasation,  contusion, 
or  laceration  of  the  brain  substance  will  be  found  at  more  spots  than 
one. 

iii.  Condition  of  the  Pupils. — Whilst  this  may  be  various,  there  are  at 
least  three  conditions  which  are  most  important. 

(a)  If  the  pupils  are  natural  as  regards  reaction  to  light,  the  com- 
pression of  the  brain  is  probably  recoverable  if  trephining  is  immedi- 
ately performed.  Furthermore,  it  is  probably  a  case  of  compression 
only  of  the  brain,  without  other  injury. 

(/5)  If  the  pupils  are  insensitive,  often  at  the  same  time  dilated,  the 
compression  is  probably  extreme,  and  while  trephining  is  urgently 
called  for,  it  is  less  probable  that  in  these  cases  the  brain  will  recover 
itself  after  removal  of  the  clot. 

(7)  If  one  pupil  is  found  widely  dilated,  the  other  being  natural  or 
contracted  in  size,  and  if  the  dilatation  be  ]iresent  on  the  side  injured, 


MIDDLE    MENINGEAL    HAEMORRHAGE.  177 

in  other  Avords,  opposite  to  the  side  paralyzed,  it  is  a  most  valuable 
sign,  tlie  explanation  of  which  we  owe  to  Mr.  Hutchinson/'^ 

Taken  with  other  evidence  of  middle  meningeal  extravasation  this 
condition  of  the  pupil  points  to  a  large  clot,  reaching  down  into  the 
base  and  j^ressing  forwards  upon  the  sphenoidal  fissure,  and  thus  com- 
pressing the  third  nerve. 

iv.  The  Pulse. — This  will  vary  according  as  the  case  is  one  of  well- 
marked,  uncomplicated  extravasation,  or  complicated  with  contusion 
or  laceration  of  the  brain  ;  and,  if  the  concussion  stage  has  been  severe, 
according  to  the  degree  to  which  the  heai't  has  recovered  from  this. 

In  well-marked  uncomplicated  compression,  the  pulse  will  be 
slower  than  normal — e.g.,  66,  52,  and  still  falling,  42,  and  usually  some- 
what full  and  laboring. 

V.  Coma,  or  Unconsciousness. — With  regard  to  this,  the  following 
points  should  be  borne  in  mind  ; 

(a)  The  degree  of  unconsciousness  will  vary  with  the  size  of  the 
branch  injured,  and  the  rapidity  with  which  the  blood  is  effused. 
Where  the  effusion  is  rapid  and  the  compression  great,  the  coma  may 
be  as  deep  and  complete  as  in  apoplexy.  But,  in  other  cases,  it  will 
be  found  that  though  the  coma  is  apparently  deep,  this  is  not  really 
so,  thus  the  patient  may  moan  constantly,  or  may  move  his  limbs 
feebly  when  disturlied. 

(/3)  The  commencing  coma  may  be  taken  for  natural  sleep,  or 
drunkenness,  in  which  conditions  the  patient  may  be  allowed  to  lie 
till  it  is  too  late. 

(j)  In  a  few  cases,  the  onset  of  the  coma  is  deferred  till  late,  its  on- 
set is  here  sudden,  its  course  rapid,  and  it  generally  ends  in  death. 

vi.  Respiration. — This,  in  well-marked  cases,  is  often  stertorous  and 
somewhat  slow.  In  cases  where  stertor  has  not  supervened  to  call  at- 
tention to  the  existence  of  compression,  other  and  still  graver  altera- 
tions in  the  breatliing  may  be  present,  alterations  Avhich  are  warnings 
that  the  end  is  not  far  off,  and  that,  in  the  case  of  intended  trephining, 
there  is  no  time  to  lose — viz.,  catchy,  short  respirations,  cj'anosis,  and 
gasping,  irregular  breathing,  ceasing  for  intervals  of  ten  or  fifteen  sec- 
onds, and  then  repeated. 

vii.  State  of  Scalp. — When  the  history  is  deficient,  or  when  the  signs 
of  compression  are  not  well  marked,  ecchymosis  or  contusion  of  the 
parietal  and  temporal  regions  giving  rise  to  a  pulpy  or  puffy  feel  are  of 
great  value.  Tliis  condition  will  be  especially  marked,  when  the 
haemorrhage  from  the  middle  meningeal  arter}^  is  finding  its  way 
through  some  fracture  into  the  tissues  of  the  scalp.f 

*  On  Compression  of  ilie  Brain  :  Lond.  Hn^p.  Reports,  1867,  vol,  iv.  p.  29 
t  Tliere  is  a  good  specimen  of  tiiis  in  St.  George's  Hospital  Museum,  Series  No.  4, 
figured  b_v  Mr.  Holmes  in  liis  Treatise  on  Swrjery,  -Itli  ed.  p.  140,  Fig.  39.     It  shows  the 

12 


178  OPERATIONS    OX    THE    HEAD    AND    NECK. 

Treatment. — Early  trephining  should  he  performed  as  follows : 
The  scalp  should  be  shaved  widely,  for  the  liberal  application  of  ice, 
later  on,  if  needful.  No  anesthetic  should  be  given  if  the  patient  is 
unconscious  or  the  respiration  failing.  The  head  being  supported  oil 
sand-bags  or  a  firm  pillow,  the  middle  meningeal  area  on  the  side 
Avhich  is  bruised,  and  on  the  side  opposite  to  the  hemiplegia,  is  ex- 
plored by  turning  up  flaps  with  a  free  crucial  incision,  the  centre  of 
which  is  li  inch  behind  the  external  auditory  meatus,  and  1  inch 
above  the  zygoma.  The  brisk  ha3morrhage  which  now  usually  takes 
place  will  be  best  arrested  by  applying  Spencer  Wells's  forceps  to  the 
bleeding  points,  the  forceps  thus  not  only  arresting  htemorrhage,  but 
acting  as  retractors  also  (Fig.  42).  The  pericranium  is  then  carefully 
separated,  and  any  fissure  or  fracture  looked  for  on  the  bone.  Whether 
one  is  found  or  no,  a  crown  of  bone  is  next  removed  with  a  full-sized 
trephine.  When  this  has  exposed  the  clot,*  haemorrhage  may  be  still 
going  on,  warning  of  which  will,  perhaps,  be  given  by  the  pulsation  of 
the  clot.  This  being  removed  by  a  small  lithotomy  scoop,  one  of 
Volkmann's  spoons,  or  the  handle  of  a  small  teaspoon,  the  haemor- 
rhage may  cease,  or  it  may  continue  profusely,  welling  up  from  a 
point  quite  out  of  reach.  In  such  cases,  the  surgeon  may,  after  saving 
his  patient  from  the  dangers  of  com})ression,  have  to  face  those  of 
most  serious  heemorrhage.  In  such  a  contingency,  the  following  steps 
may  be  made  use  of:  (1)  The  use  of  cold,  either  in  the  shape  of  large 
ice-bags  over  the  side  of  the  face,  head,  and  neck  (M.  Beck),  or,  as  a 
freezing  mixture,  three  parts  of  salt  and  two  of  ice  (Howse)  ;  (2)  Press- 
ure, by  suturing  the  edges  of  the  wound,t  or  by  digital  pressure  on 
the  common  carotid  ;  (3)  If  the  bleeding  spot  is  found  by  the  aid  of  a 
pointed  probe  to  lie  in  a  distant  bony  canal,  the  haemorrhage  may. 
perhaps,  be  arrested  by  plugging  this  canal  with  a  tiny  wooden  peg  ;  J 

parietal  bone  of  a  cliilfl,  nged  five,  in  wliioli  a  fjnjiing  fissure  c-rosses  tlie  jjroove  for  the 
middle  meningeal  artery,  producing  considerable  extravasation  inside  the  skull,  and 
still  more  externally. 

*  Perhaps  another  crown  of  bone  nuist  be  removed  to  do  this.  Thus,  in  one  case, 
when  trephining  over  the  trunk  of  the  middle  meningeal.  I  came  down  on  the  pro- 
longed tail-like  extremity  of  a  huge  clot,  reaching  far  away  upwards  and  backwards, 
and  due  to  a  branch  being  opened  at  some  distance  by  a  most  extensive  fissure. 

t  This  can  only  be  carried  out  under  certain  conditions,  as  when  the  edges  of  the 
woimd  are  clean  cut,  of  the  surgeon's  own  making,  and  also  when  the  surgeon  is  able 
to  see  his  patient  at  short  intervals,  or  to  leave  him  in  com[>etent  hands;  otherwise,  if 
the  haemorrhage  persist,  this  additional  precaution  may  increase  the  risk  of  that  com- 
pression which  the  operation  had  been  intended  to  obviate. 

X  This  was  suggested  by  Mr.  T.  Smith,  and  used  successfully  by  Mr.  Willett  and  Mr. 
H.  Marsh,  at  St.  Bartholomew's  Hospital  in  cases  of  haemorrhage  from  the  descending 
palatine  artery  {Clin.  Soc.  Trans.,  vol.  xi.  p.  71). 


MIDDLE  :mem>;geal  haemorrhage.  179 

(4)  The  above  means  failing,  which  is  unlikely,  ligature  of  the  external 
carotid  had  better  be  resorted  to* 

Whether  the  surgeon  should  remain  satisfied  with  a  single  trephin- 
ing and  partial  removal  of  the  clot,  or,  having  exposed  the  clot,  pro- 
ceed to  remove  the  skull,  and  then  the  blood,  more  extensively,  is  as 
3'et  doubtful.  For  the  present,  and  until  a  larger  number  of  cases  in 
which  trephining  has  been  performed  for  this  hfemoi'rhage  liave  been 
collected,  that  surgeon  will  probably  be  wiser  who  rests  satisfied  with 
a  simple  trephining,  using  a  full-sized  instrument  and  trusting  to  the 
"  safety-valve  action  "  f  which  this  ensures  for  the  brain. 

Prognosis. — With  reference  to  this  point,  I  may  quote  the  follow- 
ing remarks  from  my  paper  in  the  Gay''s  Hosp.  Reps.,  vol.  xliii.  : 

"  The  chief  points  on  which  this  depends  are,  whether  the  middle 
meningeal  extravasation  is  probably  complicated  with  such  injuries 
as  extensive  fractures  and  brain  injurv,  and  secondly  upon  the  date  of 
the  trephining,  and  whether,  at  this  time,  the  brain  recovers  itself 
quickly  or  not.  With  regard  to  the  former,  or  the  existence  of  com- 
plications, the  surgeon  will,  if  asked  to  state  the  probable  result,  base 
his  opinion  on  the  history  of  the  case,  the  severity  of  the  violence,  e.(7., 
height  of  fall,  whether  any  interval  of  lucidity  has  been  present,  and, 
if  so,  for  how  long  and  how  far  this  has  been  well  marked,  how  far  the 
symptoms  of  compression,  well-defined  hemiplegia,  the  falling  pulse, 
the  stertorous  breathing,  etc.,  are  present  or  replaced  by,  or  compli- 
cated with,  those  symptoms  which  are  believed  to  point  rather  to  lacera- 
tion or  contusion  of  the  brain  and  its  membranes — viz.,  restlessness, 
convulsive  movements  or  twitchings,  pulse  quick  and  sharp,  and  other 
evidence  of  pyrexia,  which  show  that  inflammation  of  the  brain  has 
probal>ly  supervened  upon  the  injury  to  its  sulistance." 

The  seventy  cases  on  which  the  above  paper  was  based  appeared  to 
fall  into  the  three  following  groups: 

A.  The  Mod  Hopeful  Cases  for  Trephining. — Violence  comparatively 
slight ;  laceration  of  middle  meningeal  artery  or  its  branches  ;  fracture 
of  skull,  if  present,  slight,  and  localized  to  side  of  skull,  i.e.,  not  impli- 
cating base ;  compression,  but  little  or  no  contusion  or  laceration,  of 
brain.     Twenty-seven  cases. 

B.  Less  Hopeful  Cases. — Violence  greater;  laceration  of  middle 
meningeal  or  its  branches ;  fracture  implicating  base,  i.e.,  middle  fossa; 
some  injury  to  brain,  but  this  only  trivial.     Twenty  cases. 

*  Ligature  of  the  common  carotid,  if  preferred,  is  justified  by  a  successful  ease  re- 
corded by  Dr.  Liddell  [Amer.  Journ.  Med.ScL,  vol.  Ixxxi.  p.  344),  in  whicli  secondary 
lisemorrhRge  from  the  middle  meningeal  artery,  three  weeks  after  a  shell  wound  in  the 
temporal  region,  was  successfully  arrested  by  ligature  of  the  common  carotid.  The  ad- 
ditional special  risks  of  this  operation  are,  however,  well  known. 

t  Mr.  Marcus  Beck,  3Icd.  Tim.es  and  Gazette,  1887,  vol.  ii.  p.  199. 


180 


OPERATIONS    ON    THE    HEAD    AND    NECK. 


C.   Cases  profxihhj  Hopeless  from    flic   Fird. — Violence   very    <,a'cat ; 
laceration  of  middle  meningeal  or  its  Ijranclies;  fracture  of  skull  very 


Fig    44. 


Middle  meningeal  haemorrhage  with  extensive  fracture  of  the  skull.  Prep.  logS'i,  Guy'.s  Hos- 
pital Museum.  From  the  severity  of  the  fracture  which  involves  vault  and  base  such  a  case 
gives  very  little  hope. 

extensive,  perhaps  implicating  several  bones  and  sutures,  both  in  vault 
and  base ;  injury  to  brain  very  severe.     Twenty-three  cases. 

TREPHINING  AND  EXPLORATION  OF  CEREBRAL 
ABSCESS  DUE  TO  INJURY. 

Indications  for  Exploring;  Symptoms  and  Diagnosis  of 
Traumatic  Cerebral  Abscess. ^ — Many  of  these  are  given  at  some- 
what fuller  length  when  that  form  of  cerebral  abscess  which  is  one  of 
the  results  of  otitis  media  is  discussed  at  p.  195.  To  begin  with,  there 
is  the  history  of  an  injury  *  with  primary  brain  symptoms,  e.g.,  con- 

*  This  may  have  been  a  stab  with  a  knife,  p.  162,  a  graze  of  head  witii  momentary 
concussion,  a  fracture,  a  blow  with  a  stone,  a  glancing  bullet,  etc.  But  the  help  in  the 
case  which  the  history  of  an  injury  gives  is  not  always  present,  and  this  is  an  indica- 
tion for  always  examining  for  any  wound  or  scar  and  exploring  it,  however  unim- 
portant it  may  seem  to  be,  in  these  cases.  Thus,  in  the  following  case  (Hulke,  Syst. 
of  Surg.,  vol.  i.  p.  626),  the  necrosis  might  have  been  overlooked,  and  the  fit  and 
rigidity  put  down  to  another  cause.  A  middle-aged  woman,  having  fallen  down  in  a 
fit  in  a  neighboring  street,  w-as  brought  to  the  Middlesex  Hospital.  She  was  uncon- 
scious, and  her  left  arm  and  leg  were  rigidly  flexed.     On  her  right  temple  was  a  small 


•     TRAUMATIC    CEREBRAL    ABSCESS.  181 

cussion  lasting  a  variable  time,  but  usuall_y  brief.  If  no  such  injur}'- 
as  fracture  and  depression  of  the  skull  exists,  and  if  no  laceration,  etc., 
of  the  l)rain  has  occurred,  there  now  often  follows  a  latent  period 
devoid  of  brain  symptoms,  which  may  last  from  a  few — e.g.,  four — 
days  to  three  or  four  weeks  or  much  longer.*  This  latent  period  is 
succeeded  by  brain  symptoms  increasing  in  severity  and  going  on  to 
those  of  compression — viz.,  headache  felt  over  the  side  injured,  but  not 
necessarily  most  intense  at  the  injured  spot;  nausea  or  vomiting; 
some  pyrexia,  but  the  temperature  usually  rises  slowly,  if  it  rises 
above  normal  at  all.f 

Other  symptoms  are  mental  dulness,  the  answers  long  delayed  but 
intelligent  when  they  come,  a  slow  pulse,  perhaps  rigors,  progressive 
emaciation,  perhaps  accompanied  by  vomiting.  Whether  local  nerve 
symptoms— f.*/.,  disturbances  of  sensation  and  motion — are  present 
must  depend  on  the  position  of  the  abscess.  If  the  injury  has  been 
over  the  motor  area  (Fig.  48),  nerve  symptoms  may  be  clearly  marked ; 
but  if  over  the  anterior  part  of  the  frontal,  or  tempero-sphenoidal;}; 


festering  wound,  leading  to  necrosed  bone.  On  perforating  this  with  a  trephine,  several 
drachms  of  pns  were  forcibly  ejected  to  some  distance  through  a  sloughy  hole  in  the 
dura  mater.  The  spastic  rigidity  of  the  left  arm  and  leg  immediately  disappeared,  but 
tiie  patient  soon  died.  At  tlie  examination  of  the  body,  the  empty  cavity  of  a  large 
abscess  was  found  in  the  anterior  lobe  of  the  right  cerebral  hemisphere. 

*  As  in  M.  Dupuytren's  and  Prof  Nancrede's  cases  at  p.  162;  so,  too,  in  a  case 
of  Mr.  Hulke's,  alluded  to  in  a  foot  note,  p.  182,  the  patient,  an  errand  boy,  continued 
to  work  for  seven  weeJcs  after  the  injury,  more  or  less  headache  being  present  all  the 
time;  retelling  and  hemiplegia  tiien  coming  on. 

t  On  this  point  I  would  refer  my  readers  to  p.  196.  Dr.  Nancrede  [loc.  supra  cit., 
p.  95)  writes  thus:  "I  believe  that  an  abscess  involving  the  cerebral  tissues  alone  will 
be  accompanied,  in  most  cases,  by  a  subnormal,  or,  at  least,  a  normal  temperature. 
Where  a  liigii  temperature  is  noted,  either  the  pus  collection  is  simply  a  localized 
suppurative  arachnitis  limited  by  adhesions,  or  there  is  a  meningitis  in  addition  to  the 
abscess."  Dr.  Nancrede  quotes  briefly  a  case  recorded  by  Dr.  H.  L  Brown  (Bost.  Med. 
and  Sury.  Journ.,  December  29th,  1881,  p.  610)  in  which  the  temperature  was  97° 
for  eleven  days.  Mr.  Hulke  (Syfft.  of  Surg.,  vol.  iii.  p  627,  628)  gives  two  cases  of 
cerebral  abscess,  in  which  he  trephined  successfully;  the  temperature  was  subnormal 
in  both.  More  rarely,  tlie  temperature  shows  considerable  fluctuations,  as  in  a  case  of 
Dr.  Burney  Yeo  {Brit.  Med.  Journ.,  1879,  vol.  ii.  p.  84)  in  which  most  remarkable 
temperatures  ranged  during  the  last  twelve  days  of  the  patient's  life,  from  94°  to  105°, 
these  being,  as  Dr.  Yeo  points  out,  roughly  divisible  into  a  period  of  high  temperature 
and  a  period  of  low  temperature.  During  the  former,  there  were  no  brain  symptoms 
proper,  and  during  tlie  latter,  there  were  brain  symptoms.  More  rarely  still,  the  tem- 
perature continues  high  throughout,  so  that  the  case  may  be  mistaken  for  one  of  con- 
tinued fever. 

X  With  regard  to  this  part  of  the  brain,  in  which,  comparatively  speaking,  large 
collections  of  pus  are  often  found,  Dr.  Yeo  (loc.  supra  cit.,  p.  885)  quotes  the  following 
remark  from  Hugenin  (Ziemssen's  Cyclopcedia,  vol.  xii.) :  "The  difficulty  of  diagnosis 
is  increased  by  the  circumstance  that  no  bands  of  fibres,  which  are  direct  conductors  of 


182  OPERATIONS    ON    THE    HEAD    AND    NECK. 

lobes,  they  may  be  entirely  absent.  Thus  hemiplegia  *  a  paralysis 
limited — e.g.,  of  upper  limb,  and,  later  on,  gradually  increasing — epi- 
leptic seizures,  spasms,  spastic  rigidity,  all  have  been  met  with,  but 
must  by  no  means  be  relied  upon,  and  even  when  paralysis  is  present 
it  may  escape  observation,  as  when  there  is  slight  paralysis  of  the 
muscles  of  the  lower  half  of  the  left  side  of  the  face,  and  some  loss  of 
power  in  the  left  hand  and  arm,  but  only  temporary.! 

Finally,  the  surgeon,  who  is  watching  what  he  believes  to  be  a 
cerebral  abscess,  must  always  remember  that  after  a  period  of  latency, 
which  may  last  weeks  or  more,  acute  symptoms  may  set  in  suddenly 
and  quickly  close  in  death. 

Such  a  case  is  given  by  Dr.  Fagge  (Medicine,  vol.  i.  p.  551).  In  1876, 
a  girl,  aged  eighteen,  was  admitted  about  5  p.m.  into  Clinical  Ward, 
Guy's  Hospital.  She  had  for  six  days  been  suffering  from  sickness 
and  diarrhcea,  with  severe  headache,  so  that  she  was  said  by  the  med- 
ical man -who  attended  her  to  have  typhoid  fever.  She  then  spoke 
rationally,  and  answered  questions  put  to  her,  but  seemed  odd  in  her 
manner.  At  8  p.m.  she  suddenly  made  a  great  noise,  then  became 
partially  insensible,  but  capable  of  being  roused.  She  seemed  to  have 
left  hemiplegia.    An  hour  later  she  all  at  once  ceased  to  breathe.;}:    In 

sensiliility,  or  motion,"  pass  through  this  lobe;  and,  tiierefore,  an  abscess  here  "  may 
attain  a  consifleral)ie  size,  and  may  cause  general  symptoms  of  compression  before  any 
distinct  symptom  of  local  disease  arouses  the  suspicion  of  a  localized  affection  of  the 
brain." 

*  Mr.  Hulke,  in  relating  the  case  of  a  boy  which  he  brought  before  the  Medico- 
Chirurgical  Society,  March  llth,  1879,  laid  stress  on  the  fact  that  hemiplegia  occurring 
some  time  after  an  injury  to  the  head  was  significant  of  disease  in  the  brain  itself 
rather  than  of  araciinitis. 

f  Tlie  value  of  accurately  noting  symptoms  which,  though  of  but  brief  duration,  may 
be  very  important  guides  in  treatment,  is  well  shown  by  a  case  of  Dr.  Macewen's 
(Lancet,  1881,  vol.  ii.  p.  582).  A  boy,  aged  eleven,  was  admitted  into  the  Glasgow 
Royal  Infirmary,  two  weeks  after  a  fall  upon  his  head,  with  a  partially  healed  wound 
and  bare  bone  over  the  left  eyebrow.  A  week  afier  admission  he  had  a  rigor  which 
was  considered  to  indicate  the  probable  formation  of  pus.  Five  days  later,  or  twenty- 
six  days  after  the  injury,  the  patient  had  a  convulsion  confined  to  the  right  side; 
when  this  had  passed  off',  he  was  distinctly  aphasic.  The  seat  of  the  abscess  now  seemed 
to  be  the  third  left  frontal  convolution,  and  trephining  was  proposed.  Tlie  friends, 
however,  refused  to  permit  this,  as  the  patient  bad  recovered  consciousness,  though  tliey 
were  warned  that  the  improvement  would  be  only  temporary.  Tliirty  hours  later,  the 
convulsions  of  the  right  side  recurred,  the  temperature  rose  quickly  from  101°  to  104°, 
and  the  patient  died  before  the  operation  could  be  performed.  The  existence  and 
situation  of  the  abscess  were  verified  after  death. 

X  This  sudden  alteration  in,  or  cessation  of,  breathing  in  cerebral  cases  is  again 
noticed  at  pp.  154,  177.  So,  too,  in  a  case  which  Mr.  Gamgee  brought  before  the 
Medico-Chirurgical  Society,  June  14th,  1879.  A  boy,  who  iiad  been  trephined  for 
suspected  cerebral  abscess,  the  pus  not  being  found,  sudilenly  ceased  breathing  the  day 
after  the  operation.     The  i)atient,  thougii  apparently  dead,  being  partly  revived  by 


TRAUMATIC    CEREBRAL    ABSCESS.  183 

this  case  four  or  five  abscesses  were  found  in  the  posterior  and  middle 
lobes  of  the  right  hemisphere.  A  case  where  this  sudden  cessation 
of  breathing  took  place,  and  life  was  temporarily  restored  by  opening 
the  cerebral  abscess,  is  given  lielow. 

Operation  of  Trephining  for  Traumatic  Cerebral  Abscess. 
— As  the  fatality  of  cerebral  abscess,  if  left  to  itself,  is  so  high — 90  to 
100  per  cent. — trephining  is  abundantly  justified,  but  it  must  be  con- 
ducted aseptically  for  fear  of  setting  up  suppurative  meningitis  and 
brain  softening.  The  chief  difftculty  is,  of  course,  hitting  off  the  seat 
of  the  abscess,  especially  in  cases  where  there  are  no  definite  nerve 
symptoms  to  guide,  and  where  the  history  of  the  part  of  the  head 
injured  is  indefinite  also.  To  obviate  the  necessity  of  multiple  tre- 
phining Dr.  Fenger  and  Dr.  Lee,  of  Chicago,  have  recommended,*  as 
easier  and  safer,  exploratory  puncture  and  aspiration.  This  must  be 
done  methodically  with  a  fine  needle,  4  inches  long,  set  in  a  large-sized 
hypodermic  syringe.  The  needle,  well  disinfected,  is  pushed,  through 
a  trephine  hole,  straight  in  in  a  definite  direction  for  2  or  1  inch  ;  the 
piston  is  then  withdrawn  a  little,  and,  if  no  pus  follows,  the  needle  is 
pushed  i  inch  further,  and  the  piston  again  withdrawn.  The  depth 
to  wliicli  it  will  be  permissible  finally  to  push  the  needle  will,  of 
course,  vary  with  the  position  of  the  trephine-opening  and  the  direction 
of  the  puncture,  the  surgeon  being  guided  by  the  anatomy  of  the 
brain.  The  punctures  are  to  be  repeated  at  intervals  of  *  inch  or  1 
inch,  the  utmost  care  being  taken  to  push  the  needle  in  straight,  and 
to  avoid  all  lateral  movements.  If,  after  a  reasonable  number  of 
punctures  no  pus  is  withdrawn,  the  operator  may  feel  convinced  that 
no  pus  is  present.  An  abscess  in  the  brain  is  usually  as  large  as  a 
walnut,  often  much  larger. 

Puncturing  healthy  brain  tissue  with  a  fine  perfectly  aseptic  needle 
can  do  Ijut  little  mischief. 

When  the  abscess  is  found  it  is  best  opened,  not  by  a  cutting  instru- 
ment, but  by  dressing-forceps,  which  can  be  pushed  along  the  needle 
as  a  guide.  The  abscess-cavity  is  tlien  washed  out  and  drained  in  the 
manner  pointed  out  at  p.  1U7. 

The  following  cases  of  cerebral  abscess,  in  addition  to  those  given 
at  p.  161,  and  in  the  footnotes  to  p.  182,  are  good  instances  of  the 
disease  and  also  of  its  successful  treatment : 

artificial  respiration,  the  dura  mater  and  brain  were  now  incised — a  step  whicli  had 
not  been  tal^en  before,  as  tlie  former  striiettire  looked  liealthy,  and  did  not  bulge 
into  the  trephine  hole— pns  welled  up,  and  the  child  survived  for  a  week.  Post- 
mortem :  an  abscess  2  inches  long,  and  still  containing  an  ounce  of  purulent  fluid, 
was  f(»und  in  the  right  frontal  lobe:  the  abscess  had  burst  externally,  causing  purulent 
meningitis. 

*  Trans.  Amer.  Surg,  Assoc,  vol.  ii.  p.  78. 


184  OPEEATIONS    ON    THE    HEAD    AND    NECK. 

A  laborer  *  aged  sixty,  was  adniitted  into  the  Middlesex  Hospital, 
under  the  care  of  Mr.  Hulke,  a  fortnight  after  being  struck  a  glancing 
blow  on  the  right  temple  by  a  falling  ladder,  which  stunned  him  for 
a  few  minutes  and  caused  a  considerable  bruise.  He  continued, 
nevertheless,  to  work  as  usual  until  the  middle  of  the  third  day,  when 
headache,  which  he  had  had  from  the  time  of  the  accident,  became 
very  severe — so  severe  that  his  wife  feared  he  would  go  out  of  his 
mind.  When  taken  into  the  hospital  the  pulse  was  56,  and  the  tem- 
perature slightly  below  the  normal.  His  mind  was  unclouded. 
About  one  week  later,  in  the  night,  he  became  insensible,  and  in  the 
morning  the  right  upi)er  and  lower  limbs  were  found  absolutely  pal- 
sied as  regards  motion,  and  nearly  so  as  regards  sensation.  When  the 
arm  or  thigh  were  severely  pinched,  he  gave  scarce  any  sign  of  con- 
sciousness of  it,  but  shrank  slightly  when  the  left  limbs  were  pinched 
similarly.  Two  days  later  spastic  rigidity  of  the  left  arm  supervened, 
A  small  disk  of  bone  cut  out  beneath  the  bruised  bone  on  the  right 
temple  appeared  uninjured.'  The  dura  mater  bulged  up  so  tensely 
that  pulsation  could  neither  be  seen  nor  felt;  its  exposed  surface 
appeared  healthy.  A  needle  connected  with  an  exhausting  syringe 
was  pushed  through  it  to  a  depth  of  H  inch.  A  brownish  turbid  fluid 
rose  up  into  the  receiver,  and  continued  to  flow  after  the  needle  was 
withdrawn.  The  minute  opening  was  enlarged  with  a  scalpel,  and  a 
considerable  quantity  of  fluid  escaped.  The  flaps,  which  had  been 
reflected,  were  replaced,  and  the  wound  was  very  lightly  dressed  with 
a  little  boric  charpie.  An  hour  later  he  asked  for  food.  Next  morn- 
ing the  spastic  rigidity  of  the  left  arm  had  gone.  On  the  second  day 
slight  return  of  power  was  noticed  in  the  right  limbs,  and  before  the 
end  of  a  week  their  palsy  had  disappeared.  For  a  very  few  days  after 
the  operation  the  charpie  was  wetted  and  discolored  by  the  fluid 
which  continued  to  ooze,  but  the  wound  soon  healed,  and  two  months 
after  the  operation  the  patient  appeared  quite  well. 

It  is  interesting  to  note  in  the  following  casef  that  the  hemiplegia 
which  followed  the  operation  was  only  transitory.  It  also  shows  that 
grave  symptoms  may  be  latent  for  as  long  as  five  months  if  a  skull 
wound  remains  unhealed. 

A  child,  aged  four  and  a  half,  had  sustained  a  severe  compound 
fracture  of  the  right  frontal  bone.  The  removal  of  some  necrosed 
portions  of  bone  led  subsequently  to  some  slight  hernia  cerebri.  A 
sinus  persisted,  but  the  child  seemed  well  in  other  respects,  until 
about  five  months  after  the  accident,  when  left-sided  convulsions 
(chiefly  of  the  muscles  of  face  and  arm)  came  on,  and  an  alarming 

*  Hulke,  Sysl.  of  Surg ,  vol.  i.  p.  628. 

f  Briefly  reported  from  the  Australian  Medical  Gazette  in  the  Ann.  of  Surg.,  Febru- 
ary, 1887,  p.  143. 


TRAUMATIC    EPILEPSY.  185 

condition  rapidly  developed.  The  sinus  was  opened  up  and  a  director 
passed  for  a  distance  of  1  inch  into  the  right  frontal  lol:)e  downwards 
and  backwards.  A  free  flow  of  fetid  pus  occurred,  and  after  the 
cavity  had  been  washed  out  with  carbolic  solution  (1  in  40),  a  drain- 
age tube  was  inserted.  The  latter  was  removed  at  the  end  of  a  fortnight. 
Left  hemiplegia  followed  the  operation,  but  it  passed  off  some  twenty- 
four  hours  subsequently.     Recovery  was  rapid  and  complete. 

TREPHINING  FOR  EPILEPSY  AND  OTHER  LATER 
RESULTS  OF  A  CRANIAL  INJURY.=^^ 

Indications. — The  surgeon  who  is  interested  in  this  matter  will 
find  much  information  in  an  excellent  paper  by  Mr.  Walsham  {St 
Barth.  Hosp.  Bep.,  vol.  xix.  p.  127),  from  which  the  following  five 
headings  are  taken  : 

i.  Local  indications  calling  for  trephining. — In  forty-four  out  of 
eighty-two  cases  the  scar  or  spot  was  painful,  tender  and  sensitive. 
Pressure  in  some  cases  caused  vertigo,  convulsive  fits,  rigidity,  or 
spasmodic  twitchings  of  some  group  of  muscles.  In  eight  there  was 
a  fistula  leading  down  to  bare  bone.     In  three  a  fissure  existed. 

ii.  Cause,  nature  and  situation  of  the  head-lesion  to  which  th<e 
epilepsy  was  ascribed. — In  sevent3'-two  out  of  eighty-two  cases  there 
was  a  distinct  history  of  some  lesion  to  the  head.  In  forty-six  out  of 
the  seventy-two  there  was  a  fracture,  which  in  twenty-six  of  the  forty- 
six  was  compound  and  depressed.f  The  exact  seat  of  the  lesion  is 
not  given  accurately  in  a  large  majority  of  the  cases.  In  forty-five 
it  was  over  one  or  other  parietal,  in  fourteen  over  the  frontal,  in  three 
over  tlie  occipital  area. 

iii.  Time  of  onset,  duration  and  character  of  symptoms. — The  time 
at  which  the  epilepsy  followed  the  injury  varied  greatly.  In  the 
majority  this  took  place  after  a  variable  period,  even  as  much  as 
thirteen  3'ears.     The  shortest  period  was  within  a  few  hours. 

The  duration  of  the  epilepsy,  after  it  had  become  established,  varied 

*  Under  this  liead  are  included,  amongst  others,  convulsive  movements,  paralysis, 
a[)hasia,  idiocy,  mania,  and  strange  alterations  in  character  and  temper.  The  char- 
acter of  the  tit,  tlie  frequency  with  which  such  accidents  as  tongue-biting  occur,  the 
tendency  of  tlie  fit  to  he  brought  on  by  eating,  and  thus  to  cause  clioking,  must  be 
taken  into  due  account  when  the  need  of  an  operation  is  being  considered. 

t  In  a  case  of  Mr.  West's,  brought  before  the  Medico-Chirurgical  Society  {Lancet, 
1879,  vol.  ii.  p.  798),  in  which  epileptic  fits  followed  on  a  fracture  of  the  skull,  com- 
plete relief  was  given  by  trephining,  though  the  fracture  was  found  to  involve  only 
the  outer  table;  the  child,  who  before  was  fatuous,  aphasic,  and  [lassing  her  excreta 
involuntarily,  is  stated  to  have  recovered  entirely.  Here  the  epilepsy  must  have  been 
due  to  reflex  irritation,  following  a  fracture  of  the  outer  table,  and  not  to  any  direct 
pressure  on  the  brain  or  its  membranes. 


186  OPERATIONS    OX    THE    HEAD    AND    NECK. 

from  a  few  days  to  twenty  years.  In  nearly  all  the  long-standing 
cases  the  fits  increased  in  severity,  the  intervals  growing  less. 

In  a  large  majority  of  cases  other  symptoms  presented  themselves 
in  addition  to  the  fits — viz.,  loss  of  memory,  moroseness,  delusions, 
even  utter  imbecility,  or  violent  madness,  constant  headache,  paralysis. 

iv.  Condition  of  the  parts  found  at  the  operation. — In  two-thirds 
of  the  cases  the  bone  was  found  either  depressed  or  variously  altered 
or  diseased.  Thus  it  was  thickened,  spongy,  carious,  necrosed,  a 
fistula  often  coexisting  in  the  two  latter.  Depression,  when  present, 
often  took  the  shape  of  a  spiculum.* 

The  dura  mater  in  the  greater  number  of  cases  was  healthy,  but  in 
gome  congested,  thickened,  vascular,  or  adherent.f 

In  sixteen  cases  nothing  was  found  at  the  time  of  the  operation  to 


*  The  term  exostosis  is  sometimes  apjilied  to  the  depressed  bone,  this,  when  circnm- 
scribed  and  osteophytic,  is  easily  dealt  with.  An  allied  condition,  rarer,  and  one 
much  more  difficult  to  deal  with,  is  described  by  Dr.  Echeverria  {Arch.  Gen.de  Med., 
1878,  t.  ii.  p.  533)  The  cause  of  the  epilepsy  was  here  found  to  be  a  conical,  irregu- 
lar projection  of  bone,  measuring  2  X  2j  inches,  compressing  the  dura  mater  and  brain, 
and  situated  very  close  to  the  superior  longitudinal  sinus,  just  to  the  left  of  the 
occipital  pr()t\iberance.  In  trephining,  the  crown  entered  into  this  exostosis,  and  the 
removal  of  the  rest  of  it  was  most  laborious,  the  operation  lasting  three  and  a  half 
hours.     The  recovery  was  ultimately  a  good  one. 

t  A  rare  condition  (Echeverria,  loc.  supra  ct.,  j).  535)  was  as  follows:  The  patient, 
aged  twenty-two,  had,  ten  years  before,  fractured  his  right  paiietal  bone.  Epileptic 
fits  began  six  months  after  the  injury,  and  their  increasing  frequency  was  associated 
with  an  extreme  degree  of  idiocy,  tlie  patient  being,  on  admission,  a  mere  automaton, 
I  without  intelligence  or  memory.  On  tiie  seat  of  fracture  being  explored,  a  kind  of 
pouch  was  found  embracing  an  old  blood  clot.  Wlien  this  was  turned  out,  the  haem- 
orrhage was  so  free  as  to  require  the  actual  cautery.  The  intellectual  faculties  were 
largely  restoi'ed  by  the  operation,  and  the  fits  were  also  much  reduced  in  frequencv. 
The  death  of  the  jiatient  took  place,  nearly  nine  months  later,  from  meningitis,  appar- 
ently due  to  exposure  to  the  sun.  An  autopsy  showed  that  the  cl3t-containing  cavity 
was  in  connection  with  the  brain-membranes,  and  apparently  continuous  witli  one  of 
the  branches  of  the  middle  meningeal  artery.  The  brain  at  this  spot  was  adherent  to 
the  membranes,  and  the  right  supra-marginal  gyrus,  and  the  right  parietal  convolu- 
tions were  nnicli  atrophied.  In  some  cases  a  cyst  may  underlie  the  seat  of  injury,  and 
be  the  cause  of  the  mischief.  Thus  {Ann.  of  Sur;/.,  vol.  iii.  No.  6,  p.  522  ;  Amer.  Journ. 
Med.  Sci,  April,  1886),  there  is  the  case  of  a  pistol-shot  wound  of  the  skull,  about  f 
inch  from  the  middle  line,  and  If  inch  from  the  hairy  scalp,  followed  by  aberra- 
tion culminating  in  marked  insanity.  Tlie  depression  in  the  foreliead  being  explored 
by  a  crucial  incision,  an  opening  in  the  skull  was  discovered  closed  by  fibrous,  not 
bony,  material.  In  the  expectation  of  finding  an  abscess  cavity,  the  needle  of  a 
hypodermic  syringe  was  thrust  through  this  tissue  in  several  directions  until  the 
barrel  was  foimd  to  be  filling  with  a  serous  fluid,  all  of  which  was  withdrawn  to 
the  extent  of  about  two  drachms.  On  emerging  from  the  auiesrhetic,  the  patient 
was  found  to  have  fully  regained  his  mental  equilibrium,  in  which  condition  he 
remained  five  months  later,  the  wound   having  promptly  heale'i. 


TRAUMATIC    EPU.EPSY.  187 

account  for  the  epilepsy/'^  Ten  of  these  sixteen  recovered,  and  seven 
were  cured  of  their  epilepsy.  It  is  difhcult  to  say  how  tlie  trephining 
cured  in  these  cases,  the  symptoms  had  Jasted  many  3'ears,  and  yet 
ceased  after  the  operation.  It  is  noteworthy  that  in  one  case,  though 
nothing  was  found  at  the  time  of  the  operation,  a  spiculum  was  found 
at  the  post-mortem  examination  not  far  from  the  trephine-hole,  thus 
pointing  to  the  advisability  of  sweeping  a  probe,  carefully  and  with 
aseptic  precautions,  around  the  circumference  of  the  trephine  opening, 
and  at  some  distance  from  it. 

V.  Residts  of  operation. — These  are  eminently  satisfactory.  Out  of 
eighty-two,  forty-eight  were  completely  cured,  and  thirteen  relieved. 
Of  the  latter,  some  have  been  quite  cured  after  a  longer  interval,  and, 
on  the  otlier  hand,  some  of  the  former  may  have  relapsed. 

Operation.t — To  begin  with,  a  painful  cicatrix  I  may  be  freely 
excised.  This  may  be  done  with  good  hope  that  nothing  further  in 
the  way  of  operation  will  be  required  in  cases  where  the  scar  is  con- 
stantly painful,  tender,  or  hot;  where  it  corresponds  to  the  course  of 
some  known  nerve,  and  in  any  case  where  the  original  wound  was 
lacerated,  or  contused,  and  slow  in  healing,  and  where  there  is  any 
chance  of  a  splinter  of  wood  or  metal  being  embedded  in  the  scar.§ 

If  it  be  necessary,  as  it  usually  is,  to  remove  a  crown  of  bone, 
appropriate  flaps  of  one  of  the  different  forms  mentioned  at  ]).  164, 
must  be  reflected  with  the  aseptic  and  other  precautions  already  given. 
Hemorrhage  being  arrested,  and  the  flaps  retracted  by  Spencer  Wells's 
forceps,  the  pericranium  is  carefully  divided  and  turned  off  the  bone,|| 
and  its  condition  noted  as  to  thickening  and  other  evidence  of  old 
inflammation.  The  bone  being  thoroughly  exposed,  the  surgeon  must 
be   prepared   for   the   following  conditions — viz.,  the  line  of  an  old 


*  In  two  of  them  nothing  was  found,  even  after  a  post  mortem  examination. 

f  It  is  worth  wliiie  to  point  out  tliat,  during  this,  the  surgeon  must  be  on  hi-;  guaixl 
for  tiie  sndden  supervention  of  epileittic  seizures  or  convulsive  movements  of  one  limh 
— €.(j.,  when  he  is  raising  a  crown  of  bone  much  thicl<ened  and  a  Iherent  to  the  dura 
mater. 

X  Prof.  Rriggs,  of  Nashville  {Trans.  Amer.  Sarg.  Assoc,  vol.  ii.  p.  116),  in  a  most 
e.xcellent  paper,  in  which  large  personal  experience  throws  much  light  upon  the  sub- 
ject, speaks  of  having  had  five  cases  of  this  cliaracter.  After  tiiorough  removal  of  the 
scar,  tiie  wound  was  left  to  heal  by  granulation  ;  in  all  the  attacks  were  arrested.  In 
one  of  Dr.  Echeverria's  cases  loc  supra  cit.},  convulsion*,  vertigo,  etc.,  were  cured  by 
the  removal  of  a  small  fibroma  adherent  to  the  frontal  periosteum  and  supra-orbital 
nerve. 

§  Dr.  Johnson  {Clin.  Soc.  Trans.,  vol  vi.  p.  35)  records  a  case  where  trismus,  facial 
neuralgia,  and  paralysis,  witii  a  recurrence  of  epilepsy  (the  patient,  aged  forty-four, 
had  been  free  from  fits  for  twelve  years),  were  caused  by  a  sharp,  angular  piece  of  flint, 
embedded  in  a  painful  cicatrix  of  the  cheek,  the  removal  of  which  was  followed  by 
complete  recovery. 

II  Or  this  structure  may  be  raised  together  with  the  flaps. 


188  OPERATIONS    ON    THE    HEAD    AND    NECK. 

fracture,  necrosis  (indicated  Ijy  a  sinus  with  prominent  granulations), 
hypertrophic  sclerosis  amounting,  in  some  cases,  to  eburnation,  and, 
on  the  under  surface,  depressed  fi-agments  of  the  internal  table,  spurs, 
or  nodules  of  bone.  An}'  sequestrum  will  of  course  be  removed.  If 
the  surgeon  finds  it  needful  to  resort  to  tre])hining,  he  will  do  so  with 
the  precautions  given  at  p.  16G,  remeniliering  that  here  he  is  especially 
likely  to  be  dealing  with  a  crown  of  l)one  of  varying  density  at  different 
points  of  its  circumference.*  It  must  be  elevated  with  particular 
caution,  as  a  spicule  may  have  m:ide  its  way  through  the  dura  mater 
and  be  pressing  on  the  brain. f 

If  the  first  crown  shows  nothing  abnormal,  a  probe  should  be  gently 
inserted  between  the  bone  and  dura  mater  and  carefully  swept  around, 
so  as  to  give  information  of  the  condition  of  the  inner  surface  of  the 
surrounding  bone.  If  the  first  crown  show  changes  which  are,  how- 
ever, not  localized  to  it,  the  trephine  must  be  applied  again  till  all 
thickened  bone  capable  of  exerting  pressure  on  the  brain  and  its 
membranes  is  removed. J 

If  no  change  can  be  found  in  tlie  croAvn  removed,  or  in  the  sur- 
rounding bone,  what  more  should  be  done  on  this  occasion?  If  there 
be  reason  to  suspect  abscess  in  the  brain,  because  the  symptoms  of  this 
condition  (pp.  180,  195)  are  present,  or  because  the  dura  mater  bulges 
up  without  pulsation  into  tlie  trephine-hole,  the  treatment  should  be 
as  directed  at  p.  183. 

Prof.  Horsley,  in  one  of  his  brilliant  cases  lately  published, §  has 
shown  how  much  it  may  be  possible  to  do  in  cases  of  epilepsy  where 
the  bone  has  already  been  removed,  and  where  the  mischief  lies  deeper 
down. 

A  patient,  aged  seven,  was  run  over  by  a  cab  and  sustained  a 
depressed,  comminuted  fracture,  with  loss  of  ])rain-substance  in  the 
situation  mentioned  beloAV.  The  fragments  of  bone  were  removed, 
and  the  wound  ultimately  healed,  although  it  suppurated  freely,  and 
hernia  cerebri  occurred.     The  patient  was  hemiplegic  for  some  time, 

*  Free  and  most  embarrassing  haemorrhage  may  be  met  with  in  sawing  tiirougii 
altered  diploe  traversed  by  large  siniis-like  venous  channels,  requiring  sponge-pressure 
before  and  after  the  operation. 

f  In  one  case  Prof.  Briggs  {loc.  supra  cit.,  p.  106),  on  elevating  the  bone,  found  that 
a  spicule  of  bone  from  its  under  surface  had  penetrated  tlie  superior  longitudinal  sinus. 
The  lifemorrhage  was  arrested  by  sponge  pressure,  and  the  patient  made  a  good  recov- 
ery. In  such  a  case,  the  sponge  shoidd  be  carefully  disinfected  and  dusted  with  iodo- 
form (p.  159). 

X  Prof.  Briggs  {loc.  supra  cit,  p.  118),  speaking  of  one  case  in  iiis  practice,  says  that 
six  large  crowns  of  the  trephine  were  found  necessary  to  surround  and  separate  the 
thickened  and  roughened  bone,  which,  after  the  angles  were  rounded  off  with  a  Hey's 
saw.  left  an  opening  as  large  as  the  palm  of  the  hand.     The  patient  was  cured. 

^   Brit.  Med  Jown.,  188(),  vol.  ii.  p.  672. 


TRAUMATIC  p:pilepsy.  189 

but  gradually  (in  seven  weeks')  the  paralysis  disappeared.  "When  aged 
fifteen,  the  ])atient  began  having  fits,  which  were  very  intermittent. 
When  aged  twenty-two,  he  was  admitted  into  the  National  Hospital 
for  Paralysis  and  Epile])sy ;  he  now  had  an  enormous  number  of  fits, 
and  for  some  days  was  in  the  status  epilepticus.  On  the  left  side  of 
the  vertex  (the  exact  site,  as  determined  by  measurement,  being  the 
centre  of  the  upper  third  of  the  ascending  frontal  convolution — that 
is,  posterior  to  the  hinder  end  of  the  superior  frontal  sulcus )  there  was 
a  quadradiate  scar,  opposite  to  the  centre  of  which  the  bone  could  be 
felt  to  be  wanting,  so  as  to  form  an  oval  opening  in  the  skull,  the  long 
diameter  of  which  was  about  an  inch,  and  parallel  to  the  sigittal  suture. 
Pressure  on  this  scar  always  gave  pain,  which  was  very  greatly  in- 
creased when  the  patient  was  suffering  from  one  of  his  paroxysms  of 
fits. 

The  fits,  which  occurred  in  batches  (at  this  time  the  patient  had 
3000  in  a  fortnight^  were  almost  always  of  the  same  character,  usu- 
all}-  commencing  in  the  right  lower  limb,  sometimes  in  both  the  right 
limbs  simultaneously.  An  example  of  a  fit  of  the  first  category  is  as 
follows : 

The  right  lower  limb  was  tonically  extended,  and  the  seat  of  clonic 
spasm.  The  right  upper  limb  was  then  slowly  extended  at  right  angles 
to  the  body,  the  wrist  and  fingers  being  flexed  ;  the  fingers  next  became 
extended,  and  clonic  spasms  of  flexion  and  extension  affected  the 
whole  limb,  the  elbow  being  gradually  flexed.  By  this  time,  spasms 
in  the  lower  limb  having  ceased,  but  those  in  the  upper  limb  continuing 
vigorously,  spasm  gradually  affected  the  right  angle  of  the  mouth, 
spreading  over  the  right  side  of  the  face,  and  followed  by  turning  of 
the  head  and  eyes  to  the  right. 

To  sum  up :  The  focus  of  discharge  was  situated  around  the  poste- 
rior end  of  the  superior  frontal  sulcus,  this  point  coinciding,  as  men- 
tioned above,  with  that  found  by  actual  measurement.  Before  going 
on  to  describe  the  surgical  treatment,  it  is  important  to  mention  that 
the  patient  was  distinctly  hemiplegic,  even  ten  days  after  the  last  fit, 
but  he  could  perform  all  the  movements  of  the  right  linjbs,  though 
about  half  as  strongly  as  on  the  left  side ;  there  was  no  afiection  of 
sensation  on  the  right  side,  while  the  reflexes,  superficial  and  deep, 
were  exaggerated  in  both  the  right  limbs. 

The  bone  around  the  old  opening  was  freely  removed,  the  dura 
mater,  arachnoid,  and  skin  being  found  to  form  a  homogeneous  mass 
of  fibrous  tissue,  the  former  being  raised  with  the  flap.  The  scar  in 
the  brain  was  found  to  be  highly  vascular,  of  a  deep  red  color,  and 
about  3  centimetres  long  and  2  broad.  The  membrane  covering 
the  brain  around  apjjeared  to  be  very  opaque,  and  the  brain  of  a 
slightly  yellower  tinge  than  usual.     The  scar  and  about  *  centimetre 


190  OPEUATIONS    OX   THE    HEAD    AND    NECK. 

of  surrounding  brain  substance  was  excised  to  the  depth  of  two  centi- 
metres. It  was  then  found  that  the  scar  penetrated  a  few  millimetres 
farther  into  the  corona  radiata  fibres  of  the  marginal  convolution. 
This  portion  was  then  removed,  and  the  wound  closed.  In  the 
removal  of  the  mass,  three  fair-sized  veins,  coming  directly  from  the 
middle  of  the  area  of  the  upper  limb,  had  to  be  ligatured,  since  they 
passed  directly  into  the  scar.  The  wound  completely  healed  in  a 
week.     The  tension  of  serum  was  twice  relieved. 

The  most  interesting  point  now  to  be  recorded  is,  that,  after  the 
operation,  the  patient  was  at  first  com])letely  paralyzed  in  the  digits 
of  the  right  upper  limb  ;  and  for  further  flexion  of  the  wrist  and 
supination  of  the  forearm.  Coupled  with  this  motor  paralysis,  there 
was  loss  of  tactile  sensibility  over  the  dorsum  of  the  two  distal  pha- 
langes of  the  fingers.  He  could  not  localize  the  touch  anywhere  below 
the  wrist  within  the  distance  of  one  internode ;  finally,  he  could  not 
tell  the  position  of  any  of  the  joints  of  the  digits.  We  have  here, 
apparently,  a  distinct  instance  of  loss  of  tactile  sensibility  and  mus- 
cular sense,  coupled  with  motor  paral^'sis,  all  due  to  lesion*  of  the 
cortex.  This  condition  of  motor  and  sensory  paralysis  gradually  dis- 
appeared in  the  course  of  the  next  two  months.  Up  to  the  time  of 
Prof.  Horsley  reading  his  paper  in  August,  1886,  the  patient  had 
no  fits. 

Most  strict  antiseptic  precautions  (infra)  should  be  made  use  of 
before  and  during  the  operation,  sufficient  drainage  should  be  pro- 
vided, and,  in  bringing  the  flaps  together,  the  drainage-tube  must  not 
be  pressed  upon  or  closed.  Great  care  must  be  taken  to  keep  the 
wound  sweet  later  on,  putrefraction  leading  to  septic  softening  and 
hernia  of  the  brain. 

Causes  of  Failure  after  Trephining  for  Traumatic  Epilepsy. 
— Amongst  these  are : 

1.  Not  hitting  off  the  right  s])ot. — It  has  already  been  mentioned 
that,  in  one  case  at  least,  a  bony  spiculum,  not  detected  at  the  time 
of  the  operation,  has  been  found,  post-mortem,  not  far  from  the  tre- 
phine hole  (p.  187).  To  prevent  any  such  condition  being  overlooked, 
it  has  been  advised  to  sweejj  a  probe  carefully  round  the  circumference 
of  the  trephine  hole,  and  at  some  distance  from  it. 

2.  Owing  to  the  long  continuance  or  to  the  amount  of  the  irritation, 
the  brain  may  be  permanently  affected.  Thus,  in  words  already 
quotedjf  there  are  cases  of  depressed  fracture  in  which  "  the  constant 


*  By  this,  Prof.  Horsley  means  the  disturbance  in  tJie  area  for  the  nppei-  limb  pro- 
duced by  the  ligature  of  the  veins  coming  from  it.  He  points  out,  hf)wever,  tliat 
it  is  very  possible  that  some  of  the  fibres  cotning  from  the  gyrus  fornicatus  in  the 
corona  radiata  may  have  been  injured. 

f  Dr.  Giinn,  loc.  supra  cit.,  {).  89. 


TRAUMATIC    EPILEPSY.  191 

irritation  lias  begotten  a  permanent  impression  upon  the  brain  and 
nervous  system  which  remains  after  the  offending  point  of  bone  has 
been  removed." 

3.  Idiocy  or  mental  weakness  persisting. — From  alterations  in 
the  membranes  or  brain  itself,  permanent  and  too  extensive  for  re- 
moval. 

4.  Neglect  of  after-treatment  both  medical  and  surgical,  but  chiefly 
the  former. — As  bearing  on  this  matter,  the  following  words  of  Prof. 
Nancrede*  are  well  worthy  of  remembrance:  "  The  operation,  indeed, 
removes  the  most  important  cause  of  the  epilepsy,  but  only  one  cause. 
The  disturbed  circulation  in  the  nervous  centres,  and  the  excessive 
mobility  of  the  nervous  system,  can  only  disappear  with  time,  and  if 
all  other  sources  of  peripheral  irritation  are  not  most  carefully  guarded 
against,  the  patient  may  be  slightly,  if  at  all,  benefited,  whereas  judi- 
cious after-treatment  will  sometimes  relieve  an  apparent  operative 
failure." 

5.  Trephining  for  fits  not  epileptic  in  character. — Mr.  Hulkef  gives 
a  most  interesting  account  of  a  case  in  which  he  trephined  for  "  anom- 
alous "  convulsive  attacks  supervening  several  months  after  a  head 
injury.  The  operation,  Avhile  it  did  no  harm,  was  useless.  Bromide 
and  iodide  of  potassium  having  been  tried  in  vain,  a  full  trial  of  val- 
erianate of  zinc  was  made,  the  fits  subsiding  under  this  treatment. 
This  fact,  the  way  in  which  the  fits  came  on,  the  slight  degree  of  un- 
consciousness, its  gradual  onset,  and  the  fact  that  occasionally  the  first 
convulsion  had  the  aspect  of  purposive  movement,  supported  the  view 
that  the  fits  were  not  epileptic,  but  hysterical,  induced  by  the  shock 
of  an  accident  in  a  person  of  unstable  nervous  system.  On  the  other 
hand,  the  traumatic  origin,  the  headache,  the  darting  pain  on  touch- 
ing the  part  injured,  were  all  suggestive  of  some  chronic  irritative  pro- 
cess, and  justified  the  operation  of  trephining. 

6.  Accidents  during  the  operation,  perhaps  the  fault  of  the  surgeon 
— viz.,(l)  middle  meningeal  haMuorrhage,  (2)  haemorrhage  from  an 
opened  sinus  (p.  159). 

7.  A  septic  condition  of  the  wound,  almost  invariably  the  fault  of 
the  surgeon,  and  bringing  about  (1)  meningitis,  (2)  hernia  cerebri,  (3) 
cerebral  abscess. 


*  Loc.  supra  ciL,  p.  102. 

t  3Ted.  Times  and  Gaz.,  1881,  vol.  ii.  p.  85.  It  is  noteworthy  that  the  bone  removed, 
and  the  dura  mater  in  this  case  being  normal,  an  aspirator-needle  was  pushed  through 
the  latter  to  the  depth  of  an  inch,  and  then  withdrawn,  as  nothing  escaped  through 
it.  For  a  few  minutes,  owing  to  the  high  intra-cranial  pressure,  cerebro-spinal  fluid 
spirted  in  a  slender  stream  for  the  distance  of  nearly  a  foot,  and  continued  to  leak 
awav  for  several  hours. 


192  OPERATIONS    OX    THE    HEAD    AND    NECK. 

TREPHINING  FOR  MASTOID  ABSCESS  AND  CEREBRAL 
ABSCESS,  THE  RESULTS  OF  OTITIS  MEDIA. 

(Figs.  45  and  46.) 

Points  on  Practical  Importance  to  the  Surgeon  in  the  Anat- 
omy OF  THE  Parts  concerned.* 

I.  Tympanum. — (a)  Roof  always  thin,  not  more  than  a  Hne  and  a 
half  in  thickness,  often  thinner.!  Through  this  inflammation  in  otitis 
media  readily  reaches  the  brain,  causing  meningitis,  subdural  or  cere- 
bral abscess,  {b)  Parts  of  the  brain  and  cerebellum  which  are  in  con- 
tact wi:h  middle  ear.  These  are  the  middle  and  back  part  of  the 
temporo-sphenoidal  lobe,  and  the  outer  and  front  part  of  the  lateral 
lobe  of  the  cerebellum.  With  regard  to  this  latter  site  of  abscess,  Mr. 
Toynbee;}:  held  that  the  greater  frequency  in  adults  of  cerebellar  ab- 
scess and,  with  this,  thrombosis  of  the  lateral  sinus,  were  due  to  the 
development  of  the  mastoid  cells  backwards,  (c)  The  mucous  mem- 
brane and  the  eiidosteum  lining  the  tympanum  are  in  most  intimate 
contact;  hence,  in  otitis  media,  caries  and  necrosis  readily  occur,  es- 
pecially if  the  blood-supply  to  the  tympanum  from  the  dura  mater  is 
cutoff.  ((0  The  skin  of  the  external  auditory  meatus  is  continuous 
with  the  membrana  tympani,  and  thus  otitis  media  may  be  set  up 
from  without,  as  well  as  by  mischief  reaching  the  tympanum  through 
(c)  the  Eustacliian  tube,  which  enters  in  front,  and  makes  the  mucous 
membrane  of  the  throat  continuous  with  that  of  the  tympanum.  (/) 
The  outlets  of  the  mastoid  cells  and  of  the  tympanum  are  inadequate 
for  drainage  in  otorrhoea,  as  man}'  of  the  mastoid  cells  lie  below  the 
level  of  their  opening  into  the  tympanum,  and  the  floor  of  the  tympa- 
num is,  in  part,  below  the  orifice  of  the  Eustachian  tube.  Tlie  results 
are  thus  favorable  to  decomposition. 

II.  Mastoid  Cells. — ((/)  Their  development  varies  with  age.  In 
adults,  if  well  marked,  they  may  measure  I5  inch  horizontally,  2  inches 
vertically,  and  reach  quite  up  to,  and  even  around,  the  lateral  sinus 
(Fig.  45).  In  these,  septic  thrombosis  and  pya:>mia  is  most  likely  to 
take  place.  {/))  Two  groups  of  cells  are  present :  (1)  The  horizontal, 
which  are  closely  adjacent  to  the  back  of  the  tympanum,  and  commu- 
nicate with  it.  This  group  constitutes  "  the  antrum,  and  is  present 
both  in  earl}'  and  late  life.  Their  size  is  that  of  a  good-sized  round 
pea.  The  antrum  is  bounded  externally  by  that  part  of  the  squamous 
bone  which  is  immediately  behind  and  above  the  external  meatus. 


*  Thet!e  should  be  studied  togetlier  witli  a  skull  and  one  or  two  sections  of  a  tem- 
poral bone,  somewhat  similar  to  that  shown  in  Fig.  45. 
t  The  bony  roof  is  occasionally  absent. 
X  See  Fig.  45. 


MASTOID    ABSCESS. 


193 


Through  thif  bone,  extremel}'  thin  in  earl}'  life,  pus  from  the  tympa- 
num may  make  its  way  externally.  After  the  second  year  it  becomes 
much  thicker,  and  this  mode  of  exit  is  cutoff.  It  is  through  this  bone 
that  the  trephine  or  drill  should  be  directed  in  opening  up  the  mastoid 
cells.  (2)  The  vertical.  These  are  not  developed  in  earlier  life  ;  later 
on  their  presence  brings  pus  nearer  the  lateral  sinus  and  cerebellum 
(^vide  svj^ra).  (c)  The  contents  of  the  cells  vary  a  good  deal,  being  in 
some  air,  in  others  marrow.  In  yet  a  third  class  the  cells  are  largely 
obliterated  by  old  sclerosing  ostitis,  (rf)  The  passage  of  veins  from 
the  tympanum  and  mastoid  cells.  These  fall  into  three  chief  groups: 
(1)  those  opening  into  the  lateral  sinus  ;  (2)  those  passing  through  the 
mastoid  foramen  into  the  occipital  vein  and  the  soft  parts  outside  the 
skull ;  (3)  those  running  through  the  petro-squamosal  suture  to  the 

Fig.  45. 


A  section  of  a  temporal  bone  showing  the  mastoid  cells,  both  horizontal  and  vertical, 
with  the  close  proximity  of  the  lateral  sinus.    (Toynbee.) 


dura  mater.  All  these  veins  carry  sheaths  of  connective  tissue,  and 
thus  inflammatory  products  may  reach  (a)  the  lateral  sinus,  causing 
sepiic  phlebitis ;  (6)  the  soft  parts  outside,  causing  periostitis,  celluli- 
tis, etc.;  (c)the  dura  mater  and  brain,  causing  meningitis  and  abscess. 

Four  Results  of  Otitis  Media  which  may  come  under  the 
Notice  of  the  Surgeon. — (i.)  Acute  inflammation  of  mastoid  cells : 
mastoid  abscess ;  (ii.)  abscess  in  brain  or  cerebellum  ;  (iii.)  aseptic 
thrombosis  of  sinuses  and  pyemia ;  (iv.)  meningitis.  N.B. — The 
above  four  often  coexist,  and  thus  the  sjanptoms  may  be  much  blended 
together  and  confusing. 

(i.)  Acute  Inflammation  of  Mastoid  Cells:  Mastoid  Abscess. — 
Symptoms. — These  vary  much.  There  are  two  quite  distinct  conditions 
to  remember.  Tlie  more  the  periosteum  over  the  mastoid  process  is 
involved,  the  more  clear  are  the  symptoms  and  the  more  certain  will 

13 


194  OPERATIONS    ON    THE    HEAD    AND    NECK. 

be  the  relief  from  a  sufficient  incision.  The  less  the  periosteum  and 
the  soft  parts  are  involved,  or  the  more  altered  the  bone  by  old  scle- 
rosing ostitis  due  to  prolonged  irritation,  the  less  evident  and  decided 
are  the  symptoms,  and  the  less  likely  is  an  incision  to  relieve. 

Indications  for  interfering  by  Incision  or  Trephining. — History  of  old 
otitis  media,  with  long-continued  discharge  and  deafness.  Pain  in 
and  behind  the  ear,  over  the  temple  or  occiput,  unrelieved  by  ice, 
leeches,  fomentations,  etc.  Mastoid  tenderness,  swelling,  redness, 
oedema.  N.B. — The  last  three  are  by  no  means  always  present  in 
mastoid  abscess.  Discharge  fetid,  and  unrelieved  by  washing  out 
with  lotions,  e.g.,  mercury  perchloride  (1  in  2000),  saturated  boracic 
acid,  etc.,  followed  by  the  insufflation  of  powders,  e.g.,  boracic  acid 
finely  powdered,  3  parts,  iodoform  1  part.  Drowsiness,  torpor,  but 
absence  of  the  graver  symptoms,  pointing  to  cerebral  abscess,  pyaemia, 
or  meningitis  (vide  infra,  pp.  196,  197). 

Wilde^s  Incision. — The  parts  being  shaved  and  cleansed,  and  an 
anaesthetic  cautiously  given,  a  free  incision  is  made  with  a  strong- 
backed  scalpel  down  to  the  bone  from  the  base  to  the  apex  of  the 
mastoid  process,  z  inch  behind  the  auricle.  The  condition  of  the 
periosteum  is  then  noted;  if  it  is  not  much  softened,  if  there  is  no 
marked  escape  of  pus,  etc.,  the  bone  must  be  investigated.  If  any 
soft,  carious,  or  bare  spot  is  found,  the  cells  must  be  opened  np  wdth 
a  drill,  brad-awl,  gouge,  or  trephine.  All  caseous  pus  and  foul  granu- 
lation-material must  be  removed  with  a  sharp  spoon,  syringing,  etc. 
A  short  drainage-tube  is  then  inserted,  or  one  passed  between  the 
antrum  and  external  auditory  meatus,  if  possible. 

Trephining  Mastoid  Cells. — If  on  exploration  the  bone  is  not  altered, 
or  if  the  above  incision  does  not  relieve,  the  cells  must  be  freely 
opened  up  by  trephining.  The  above  incision,  if  present,  is  converted 
into  a  T  above,  or  a  crucial  one  made,  and  a  small  trephine  applied 
immediately  behind  the  auricle  (Fig.  46),  on  a  level  with  the  external 
auditory  meatus,  and  directed  forwards  and  inwards,  especially  in 
children,  owing  to  the  close  proximity  of  the  lateral  sinus.  After 
sawing  for  i  or  i  inch,  the  crown  removed  will  be  found  to  have 
penetrated  the  cells.  These  are  then  to  be  freely  opened  up  with  a 
gouge,  cleansed  as  far  as  possible,  and  disinfected  as  explained  above. 
As  good  a  dressing  as  any  to  apply  afterwards  is  lint  wrung  out  of 
saturated  boracic-acid  lotion,  kept  moist,  and  frequently  renewed, 
iodoform  being  dusted  on  occasionally,  and  the  middle  ear  frequently 
syringed  out.  The  bowels  should  be  freely  opened,  and  limited,  light 
diet  given  at  first. 

I  much  prefer,  for  opening  up  the  mastoid  cells,  a  small  trephine 
(with    4-inch  crown)  to  any  of  the  various  drills.     Save  in  early  life, 


ABSCESS    IN    BRAIN    OR    CEREBELLUM. 


195 


the  cells  are  somewhat  complicated,  their  contents  often  most  fetid, 
and  a  thorough  opening  up  is  urgently  required.     This,  it  seems  to 


Fig.  46. 


Trephining  the  mastoid  cells.  The  auricle  is  drawn  forwards.  The  direction  of  the  trephine 
is  too  much  upwards.  Above  is  shown  the  under  surface  of  the  disk  of  bone  removed,  with  the 
cells  opened. 

me,  is  most  thoroughly  and  speedily  done  by  a  small  trephine  applied 
and  directed  as  advised. 

Hannorrhage  during  and  after  the  operation*  is  occasionally  trouble- 
some, especially  when  the  tissues  are  soft  and  almost  rotten,  and 
ligatures  difficult  to  apply.  Such  haemorrhage  is  best  met  by  forcible 
pressure,  made  use  of  with  Spencer  Wells's  forceps.  Thus,  in  one  case 
where,  after  successful  opening  of  the  mastoid  cells,  in  a  patient 
admitted  with  erysipelas  of  the  scalp  and  mastoid  abscess,  secondary 
haemorrhage  took  place  a  few  days  later  from  the  posterior  auricular 
artery.  The  tissues  from  their  condition  not  holding  a  ligature,  and 
breaking  away  with  torsion,  I  applied  a  pair  of  the  above-named 
forceps.  When  they  came  away  on  the  fifth  day  no  further  hamor- 
rhage  had  taken  place,  and  the  case  made  a  good  recovery. 

(ii.)  Abscess  in  Brain  or  Cerebellum. — (A)  When  in  the  brain 
the  collection  of  pus  is  usually  in  the  middle  and  back  part  of  the 
temporo-sphenoidal  lobe;  (B)  when  in  the  cerebellum,  in  the  front 
and  outer  part  of  the  lateral  lobe. 

Symptoms. — These  are  often  rather  negative,  no  special  nerve  symp- 
toms being  called  out  in  the  above  regions,  as  is  the  case  with  an 
abscess  in  the  motor  area.     There  is  a  history,  perhaps,  of  mastoid 

*  If  the  lateral  sinus  has  been  accidentally  opened,  the  treatment  must  be  that 
given  at  p.  159.  This  complication  is,  however,  a  very  serious  one  here,  owing  to 
the  difficulty  of  keeping  the  wound  sweet,  and  thus  of  preventing  septic  phlebitis. 


196  OPERATIONS    ON    THE    HEAD    AND    NECK. 

suppuration,  with  the  symptoms  given  above,  unrelieved  by  treatment. 
Amongst  the  most  important  symptoms  are  drowsiness,  deepening 
into  coma  ;  while  power  of  speech  remains  the  answers  are  unwillingly 
given,  delayed,  but  intelligent ;  "  sluggish  but  perfect  cerebration  " 
(Barker*) ;  vomiting  (this  is  occasional,  or  ceases  after  a  day  or  two), 
not  constant  and  incessant ;  one  or  two  rigors  may  occur  at  the  com- 
mencement of  the  abscess-formation,  but  they  are  not  commonly 
repeated;  the  temperature  is  subnormal,  e.r/.,  97°,  and  falling;  the 
pulse  slow,  e.g.,  65-50  ;  optic  neuritis  ;  f  progressive  emaciation  ;  obsti- 
nate constipation.  Special  symptoms  of  nervous  disturbance — e.g., 
hemiplegia,  paralysis  of  face,  ptosis,  alteration  of  pu})il — are  either 
absent  or  present  only  later  on.  The  following  symptoms  are  most 
grave,  and  point  to  a  fatal  termination  being  not  long  delayed — viz., 
iividity,  irregular  pulse,  tracheal  rales,  pulmonary  crepitation,  incon- 
tinence of  excreta,  tremors,  and  cervical  swelling  along  the  internal 
jugular  vein,  and,  of  course,  evidence  of  pyaemia  or  meningitis,  these 
conditions  often  coexisting. 

Treatment. — Early  aseptic  trephining  :  sites  (A)  In  the  Brain. — Mr. 
Barker;};  thinks  that  nine-tenths  of  abscesses  in  the  brain  lie  within  a 
circle  with  a  f-inch  radius,  whose  centre  lies  li  inch  above,  and  the 
same  distance  behind,  the  centre  of  the  bony  meatus.  This  corre- 
sponds to  the  posterior  inferior  angle  of  the  parietal  bone,  and  the 
lower  and  back  part  of  the  temporo-sphenoidal  lobe.  Dr.  Macewen 
found  a  cerebral  abscess,  and  dealt  with  it  successfull}^  by  trephining 
at  a  point  2  inch  above  and  i  inch  behind  the  centre  of  the  meatus. 
Mr.  Hulke  found  an  abscess  by  applying  the  trephine  over  the  squa- 
mous bone,  1  centimetre  above  the  external  auditory  meatus. 

B.  In  the  Cerebellum. — Mr.  Hulke  §  found  a  cerebellar  abscess  by 
trephining  just  below  the  inferior  curved  line,  2  centimetres  behind 
the  mastoid  i3rocess. 

Steps  of  the  operation  of  trephining  for  brain  abscess  in  connection 
with  otitis  media. — The  tympanum  and  mastoid  cells  being  rendered 
as  aseptic  as  possible,  the  head  is  shaved,  and  an  anaesthetic  cautiously 
given  (p.  178). 

Appropriate  flaps  being  turned  up,  and  haemorrhage  arrested  by 
applying  Spencer  Wells's  forceps,  a  2-inch  trephine  is  applied  over  the 
spot  selected  (according  as  the  pus  is  believed  to  be  in  the  temporo- 
sphenoidal  lobe,  or  in  the  cerebellum),  and  worked  cautiously,  owing 
to  the  thinness  of  the  bone  in  these  regions.     The  crown  removed 

*  Lancet,  1887,  vol.  i.  p.  1177. 

f  This  is  present  also  in  mastoid  inflammation  without  cerebral  abscess,  and  persists 
for  some  time  after  the  case  has  been  relieved  by  opening  up  the  cells. 

X  Brit.  Med.  Journ.,  December  11,  1886.     Afan.  of  Surcj.  Operations,  p.  400. 
I  Lancet,  July  3, 1886. 


PHLEBITIS   OF   SIXUSES.  197 

should  not  show  any  of  the  groove  for  the  lateral  sinus,  nor,  if  pos- 
sible, any  middle  meningeal  branch.  If  the  latter  is  in  the  way, 
crossing  the  dura  mater,  it  should  be  secured  with  two  ligatures,  or 
the  opening  in  the  bone  enlarged.  The  dura  mater  being  next 
divided,  a  little  arachnoid  fluid  may  escape,  and  the  brain  which 
bulges  forwards,  witliout  pulsation,  may  show  l3aiiph  upon  its  surface, 
and  yet  the  case  end  successfuU}^  if  the  pus  is  evacuated.  A  fine 
trocar  or  asj^irator  needle  (without  making  any  vacuum),  is  next 
slowly  inserted  either  straight  in,  or  in  a  direction  downwards,  for- 
wards, and  inwards  towards  the  apex  of  the  petrous  bone.  If  the 
abscess  is  struck,  bubbling  of  foul  gas,  or  a  few  drachms  of  foul  pus 
will  escape,  when  the  needle  has  entered  to  a  depth  of  5  or  f  of  an 
inch.  The  puncture  is  then  enlarged  with  a  director  and  dressing- 
forceps,  and  the  abscess-cavity  syringed  out  with  boracic-acid  lotion. 
A  short  drainage  tube  should  be  inserted  into  this  cavity, and  the  flaps 
so  arranged  as  not  to  interfere  with  free  drainage.*  The  wound  is 
then  dusted  with  iodoform,  and  sal  alembroth  gauze  or  other  aseptic 
dressings  applied.  The  drainage-tube  should  be  retained  as  long  as 
any  cavity  exists,  probably  for  two  or  three  weeks,  being  shortened 
very  gradually.  The  treatment  should  be  rigidly  asejotic,  in  order  to 
secure  early  healing,  and  to  prevent  the  risk  of  softening  and  hernia 
cerebri. 

The  two  following  complications  of  otitis  media  do  not  admit  of 
surgical  interference^  save  in  the  case  of  the  abscesses  of  pyaemia,  but 
as  they  often  coexist  with  mastoid  suppuration  and  cerebral  abscess, 
and  thus  are  liable  to  render  the  diagnosis  obscure,  and  the  prognosis 
difficult,  they  are  briefly  given  here. 

(i.)  Phlebitis  of  Sinuses,  usually  Septic,  (ind  producing  Pysemia. — Symp- 
toms.— Repeated  rigors ;  sweating ;  oscillation  of  temperature ;  sweet 
"ferment  breath";  and  a  cord-like  feel  along  internal  jugular,  with, 
perhaps,  tenderness  here.  Treatment. — This  is  usually  fruitless.f 
Three  main  indications  must  be  fulfilled.  (1)  To  get  tympanum  and 
mastoid  cells  clean  ;  (2)  To  su})port  the  strength  ;  (3)  To  meet  com- 
plications— e.g.,  pleuro-pneumonia  and  abscesses. 

(ii.)  Meningitis. — The  history  of  old  otitis  media  will  be  obtainable. 


*  Part  of  these  should  be  cut  away,  if  needful,  for  this  purpose. 

t  Prof.  Horsley  {Clin.  Soc.  Trans.,  vol.  xix.  p.  290),  recording  a  case  in  which  he 
trephined  for  mastoid  suppuration,  and  in  which  recovery  took  place,  though  throm- 
bosis of  the  right  lateral  sinus  was  believed  to  exist,  leading  to  septic  embolism  of  the 
heart  and  left  lung,  suggests  that,  as  sof)n  as  the  first  indication  of  embolism  appears, 
the  internal  jugular  vein  should  be  tied  in  the  middle  of  the  neck,  though,  as  he  points 
out,  a  serious  argument  against  the  performance  of  tiiis  operation  "  lies  in  the,  at  pi3s- 
ent  impossible,  task  of  discovering  how  much  thrombosis  there  is,  and,  further,  what 
risk  there  is  of  embolism  from  the  same." 


198  OPERATIONS    ON    THE    HEAD    AND    NECK. 

Symptoms. — Amongst  these  are,  the  intense  headache,  tantamount  to 
agony,  the  sudden  cries,  the  high  temperature,  and  perhaps  rigidity 
of  the  neck.  Treatment. — Probably  altogether  hopeless.  Iced  towels 
or  iced  irrigation,*  opium  and  calomel,  morphia. 

OPERATIVE  INTERFERENCE  IN  THE  CASE  OP 
FOREIGN  BODIES  IN  THE  BRAIN. 

Under  the  above  heading  such  bodies  as  bullets,  knife-points,  etc., 
are  included.  Depressed  and  isolated  fragments  of  bone  may  come 
within  the  meaning  of  foreign  bodies,  but  have  already  been  consid- 
ered (p.  156). 

A.  Bullets. — The  following  sites,t  being  those  in  which  a  hospital 
surgeon  is  usually  called  upon  to  treat  bullet  wounds,  may  be  briefly 
alluded  to  : 

i.  The  mouth. — This  may  be  passed  by  at  once  as  the  bullet  usually 
so  damages  the  base  of  the  skull  as  to  cause  rapid  death.  It  is  just 
worth  while  to  mention  a  possible  cause  of  fallacy  here,  and  that  is, 
that  a  small  revolver  bullet,  leaving  an  almost  impenetrable  track  in 
the  soft  parts  which  have  closed  over  it,  may  lodge  in  the  upper  cer- 
vical vertebrae,  becoming,  as  it  were,  encapsuled,  and  lead  to  no  future 
harm. 

ii.  The  forehead. — From  the  presence  of  sinuses  more  or  less  devel- 
oped, and  of  tw^  tables,  the  progress  of  the  bullet  may  be  quickly  ar- 
rested. The  well-known  fact  that  patients  frequently  recover  after 
very  severe  injury  to,  and  loss  of  substance  of,  the  frontal  lobes  should 
also  be  remembered. 

iii.  The  side  of  the  head.— The  thinness  of  parts  of  the  skull  here, 
especially  the  squamous  bone,  the  subjacent  motor  area,  the  possibil- 
ity of  middle  meningeal  hsemorrhage,  either  at  the  time,  or  when  the 
wound  is  explored,  may  be  all  points  of  importance. 

The  following  questions  will  suggest  themselves  to  the  surgeon 
when  he  is  called  upon  to  examine  a  case  of  penetrating  bullet  wound 
of  the  skull : 

1.  Has  the  bullet  penetrated  the  skull  at  all?  Thus  it  may  have 
lodged,  rebounded,  or  fallen  out,  or 


*  Mr.  Keetley  {Clin.  Soc.  Trans.,  vol.  xii.  p.  145)  records  acase  of  severe  traumatic 
meningitis,  treated  successfully  in  tlie  stage  of  coma,  by  the  cold  douche,  continued  for 
two  and  a  half  hours.  This  mode  of  treatment  deseives  a  more  energetic  trial  at  the 
liands  of  surgeons  in  their  treatment  of  meningitis. 

t  Mr  Barwell  {Clin.  Soc.  Trans-,  vol.  xviii.  p.  2.32)  makes  the  following  observation 
which  is  of  importance  if  it  is  found  to  be  constant — viz  ,  that,  though  the  weapon  may 
be  held  very  close,  there  will  be  neither  scorching  nor  powder-tattooing,  if  the  bullet 
be  driven  by  one  of  the  modern  fulminates,  contained  in  the  same  cap  with  the  pro- 
jectile. 


FOREIGN    BODIES    IN    THE    BRAIN.  1£9 

2.  It  may  have  passed  between  the  bone  and  dura  mater,  without 
penetrating  the  hitter,  and  reached  a  spot  quite  out  of  sight.  In  such 
cases  Sir  T.  Longmore  advises  the  use  of  a  curved  ^obe,  and  extrac- 
tion of  the  bullet  "  with  suitable  instruments,"  if*itcan  be  felt.  Prob- 
ably in  most  hands  a  second  application  of  the  trephine,  if  needful, 
at  some  distance  from  the  wound,  so  as  to  extract  the  bullet  here, 
would  be  preferable  to  attempts  at  removing  it  from  the  original 
wound. 

3.  Has  the  ball  split  into  two  or  more  pieces  ?  Balls  elongated  as 
well  as  round  are  liable  to  split  when  impinging  on  sharp  angles  of 
bone.  Thus,  when  the  ball  splits  upon  the  outer  table,  part  may  pass 
beneath  the  scalp,  while  the  rest  may  drive  on  before  it  some  of  the 
internal  table,  causing  pressure  on  the  dura  mater,  or  even  reach  the 
brain. 

4.  Has  the  bullet  penetrated  the  brain?  If  so,  where  does  it  lie? 
Ought  any  further  exploration  to  be  performed,  and  if  so,  ought  this 
to  be  done  through  the  original  wound  only,  or  at  some  counterpoint 
as  well? 

Before  attempting  to  answer  these  last  questions  it  may  be  well  to 
try  and  give  an  answer  to  the  question  which  will  be  sure  to  arise  in 
the  surgeon's  mind  when  called  to  a  bullet-wound  of  the  skull — viz., 
Shall  I  explore  this  or  treat  it  expectantly  ? 

The  following  appears  to  me  to  decide  in  favor  of  exj^ioring  in  all 
cases  in  which  it  is  clear  that  the  injury  is  not  going  to  be  quickly 
fatal : 

a.  The  fact  that  only  by  exploring  will  the  surgeon  be  able  to  an- 
swer the  question  certain  to  be  put  to  him  by  the  friends  whether  the 
brain  is  injured  or  no. 

b.  Whether  the  bullet  has  split,  Avhether  the  internal  table  is  shat- 
tered, and,  if  so,  how  far  it  resembles  a  punctured*^  fracture,  are  also 
points  which  can  alone  be  cleared  up  by  trephining. 

c.  Good  drainage,  disinfection  of  the  wound,  are  almost  hopeless 
unless  this  is  opened  up  and  explored  by  trephining  if  needful. 

The  following  case  is  not  only  a  good  instance  of  the  kind  of  gun- 
shot injury  to  the  head  which  may  be  met  with  in  civil  practice,  but 
it  shows  how  slight  may  be  the  injury  which  actually  originates  the 
fatal  mischief.  It  was  brought  before  the  Clinical  Society  by  my  col- 
league Mr.  Lucas.f 

*  Excellent  instances  of  how  closely  some  gun-shot  fractures  may  resemble  the  clas- 
sical "  punctured"  fractures,  not  only  in  the  greater  damage  to  the  internal  table  co- 
existing with  but  sliglit  mischief  externally,  but  also  in  the  onset  of  grave  syniptoms 
inevitably  fatal  unless  trephining  has  been  performed  early,  are  shown  in  Figs.  79  to 
88,  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  pt.  i.  pp.  168,  169. 

t  Vol.  xii.  p.  5. 


200  OPERATIONS    ON    THE    HEAD    AND    NECK. 

The  patient,  aged  twenty-one,  had  shot  himself  with  a  small  revol- 
ver. "  He  was  brought  to  the  hospital  about  half-past  eleven  in  the 
evening  in  a  semi-conscious  state.  Almost  in  the  centre  of  his  fore- 
head were  two  small  circular  holes,  with  slightly  inverted  edges. 
The  skin  surrounding  the  bullet-holes  was  raised  into  a  rounded  emi- 
nence. There  was  some  bleeding  from  tlie  nose  as  well  as  from  the 
wounds.  Chloroform  was  administered,  and  a  crucial  incision  made 
over  the  wound.  On  turning  back  the  flaps,  a  blackened  cavity  was 
opened  beneath  the  skin,  formed  by  the  expansion  of  the  powder 
after  it  had  penetrated  the  integument.  At  the  bottom  of  this  cavity 
a  somewhat  cruciform  aperture  was  seen  in  the  bone,  and  lying  upon 
the  internal  table  were  two  flattened  bullets.  The  internal  table  was 
driven  back  so  as  to  give  the  appearance  of  a  sinus,  in  which  the  bul- 
lets were  lying  loose;  and  at  the  time,  we  were  under  the  impression 
that  the  man  had  very  large  frontal  sinuses,  which  had  been  opened 
by  the  bullets.  After  removing  numerous  fragments  belonging  to  the 
external  table  and  diploe,  the  splintered  internal  table  forming  the  pos- 
terior Avail  of  the  cavity  was  also  removed.  This  came  away  in  large, 
sharp-edged  angular  fragments,  two  of  which  were  grooved  by  the 
longitudinal  sinus.  When  the  internal  table  had  been  removed  the 
dura  mater  was  seen  at  the  bottom  of  the  wound,  and  pulsating.  The 
membrane  was  entire  except  at  one  spot,  wdiere  there  was  a  small 
aperture  just  such  as  might  be  made  by  stabbing  the  point  of  a  pen- 
knife into  a  sheet  of  paper.  But  for  that  small  puncture  it  is  not  im- 
probable that  he  would  have  recovered."  Septic  meningitis  came  on 
in  about  forty-eight  hours,  followed  by  death  early  on  the  sixth  day. 

Exj)loration,  with  or  without  trephining,  in  these  cases  should  be 
conducted  on  the  lines  already  laid  down  (p.  164j.  The  chief  differ- 
ences are  only  in  degree — viz.,  the  greater  care  with  which  all  frag- 
ments should  be  removed.  Occasionally,  portions  of  the  bullet  are 
found  embedded  with  very  great  firmness  in  the  diploe,  these  are  best 
removed  by  careful  use  of  gouge  or  chisel.  If  the  dura  mater  is  found 
to  be  injured,  every  attempt  should  be  made  to  disinfect  this  from  the 
first,  and  so  obviate  the  otherwise  inevitably  fatal  arachnitis.  With 
blunt-pointed  scissors,  the  aperture,  if  small,  should  be  opened  up, 
and  a  little  iodoform,  or  equal  parts  of  this  and  finely  powdered  bo- 
racic  acid,  dusted  within  the  cavity  of  the  arachnoid  ;  or  with  a  camel 's- 
hair  brush  the  parts  may  be  carefully  wiped  over  with  a  solution  of 
mercury  perchloride  (1  in  500  or  800),  and  the  above  powder  dusted 
on.  An  adequate-sized  drainage  tube  should  be  carried  quite  up  into 
the  skull  opening,  and  retained  in  position  here  by  strips  of  gauze 
carefully  packed  around.  No  sutures  should  be  used,  as  a  rule,  in 
these  wounds  where  swelling  of  the  scalp  (it  being  impossible  to  ren- 
der the  parts  rigidly  aseptic)  is  sure  to  follow,  and  is  very  likely  to  in- 


REMOVAL  OF  BULLETS  FROM  THE  BRAIN.  201 

terfere  with  the  escape  of  discharges,  and  where  primary  union  cannot 
be  expected. 

If,  after  exploring,  the  surgeon  is  certain  that  tlie  bullet  has  pene- 
trated the  brain,  another  question  arises  as  to  the  wisdom  of  further 
exploration  and  attempts  at  removal.  As  a  rule,  if  the  bullet  is  not 
found  within  one  or  two  inches  of  the  skull  injury,  nothing  more 
should  be  done  now,  especially  if  the  patient's  condition  is  not  good, 
or  the  anaesthetic's  influence  not  well  maintained.  It  is  needless  to 
say  that  in  exploring  the  track  in  the  brain  the  utmost  gentleness  is 
essential.  As  with  fine  metal  probes,  owing  to  the  peculiar  consistence 
of  the  brain,  it  is  very  easy  to  lose  the  track,  and  thus,  at  the  same 
time,  inflict  fresh  mischief,  it  will  be  wiser  to  make  the  gentlest  pos- 
sible use  of  a  bougie  (those  with  a  double-silk  web  are  the  most  suit- 
able) after  placing  it  for  a  few  minutes  in  a  solution  of  carbolic  acid 
or  mercury  perchloride.  If  the  bullet  is  found  within  one  or  two 
inches  of  the  skull  wound,  it  should  be  removed  with  a  fine-pointed 
pair  of  dressing-forceps.  It  will  be  wise,  if  the  track  in  the  brain  is 
mucli  lacerated,  to  treat  it  like  an  abscess,  and  introduce  a  soft  drain- 
age-tube, to  be  gradually  shortened. 

The  following  points  may  be  adduced  for  and  against  the  attempt 
to  remove  bullets  which  have  lodged  in  the  brain  : 

The  surgeon  who  decides  to  abide  by  the  expectant  treatment  in 
these  cases  both  immediately  after  the  injury  and  later  on,  can  justify 
his  course  by  a  sufficient  number  of  cases.  Of  these,  one  or  two  may 
be  usefully  referred  to. 

Dr.  Brunton^  brought  before  the  Medical  Society  the  case  of  a 
patient  who  had  lived  twenty-nine  years  after  a  gunshot  wound  of  the 
brain.  He  had  fired  a  pistol  at  his  forehead,  but  the  recovery  was 
eventuall}^  so  satisfactory,  that  it  was  believed  that  the  bullet  had 
glanced  off,  or  that  the  pistol  had  contained  a  blank  charge.  The 
patient  carried  on  his  business  as  a  corn-mercluint  for  twenty-nine 
years,  married,  and  had  children.  He  was  said  to  be  excitable  in  tem- 
perament, but  his  intellect  was  clear.  Death  eventually  taking  place 
from  sciatica  and  Ijladder  trouble,  it  was  found  that  the  bullet  had 
entered  the  left  frontal  bone  at  the  inner  part  of  the  frontal  sinus,  audi 
lodged  in  the  inner  table,  projecting  through  it,  and  pressing  on  the 
membranes,  destroying  them  in  situ  and  also  a  portion  of  the  second 
and  third  convolutions  of  the  left  frontal  lobe.  There  was  no  pus  or 
artificial  membrane  present,  simply  thickening  of  the  membranes. 

This  can  scarcely  be  considered  as  a  case  of  a  bullet  lodging  in  the- 
brain.  It  will  be  noticed  that  the  velocity  of  the  bullet  was  probably 
delayed  by  its  passing  through  the  frontal  sinuses,  and  that  the  part 

*  Lancet,  February  12,  188L 


202  OPERATIONS    ON    THE    HEAD    AND    NECK. 

of  the  brain  injured  is  one  which  is  notorious  for  its  power  of  recovery 
(cf.  Mr.  T.  Smitli's  case,  Lancet,  May  3,  1879).  In  such  cases,  for  the 
future,  it  would  be  always  interesting  to  know  something  of  the  bore 
of  the  pistol  and  size  of  the  bullet. 

In  the  next  case,  the  recovery  seems  to  have  only  taken  place  after 
the  patient  had  had  a  very  narrow  escape. 

Dr.  Barton  reports  a  case  of  recovery  after  lodgment  of  a  bullet  inside 
the  cranium.  The  bullet,  weighing  34  grains,  fired  from  a  small 
Remington  pistol,  had  entered  the  skull  2  inches  above  a  horizontal 
line  drawn  just  above  the  eyebrow,  and  about  i  of  an  inch  to  the  left 
of  the  middle  line. 

At  first  there  appeared  only  a  puncture,  then  ecchymosis  around  the 
wound.  On  the  fourth  day  a  globular  pulsating  swelling  of  the  scalp 
appeared  here,  and  a  probe  could  be  j^assed  straight  backwards  into  the 
cranial  cavity,  being  only  stopped  by  the  fingers.  A  drachm  of  cerebro- 
spinal fluid  now  escaped,  and  symptoms  of  compression  which  were 
present  {e.g.,  a  pulse  of  44)  were  relieved.  Carbolic-oil  dressings  were 
applied.  The  patient  now  made  a  good  recovery  up  to  the  fortieth  day, 
when  suddenly  violent  pain,  rigors,  delirium  and  convulsions  set  in. 
Calomel  and  opium  were  given,  and  the  patient  made  a  good  recovery, 
being  perfectly  well,  in  all  respects,  five  months  after  the  accident.  The 
history  is  not  carried  beyond  this  date.* 

The  following  case  t  is  noteworthy  as  showing  the  course  of  a  bullet 
which  had  traversed  so  great  a  thickness  of  soft  parts  that,  though  it 
entered  the  skull,  it  did  not  penetrate  the  brain. 

The  patient  had  shot  himself  with  a  pistol.  Just  behind  the  angle 
of  the  jaw  was  a  small  dark  inverted  wound  immediately  in  front  of 
the  carotid  vessels.  On  the  left  temple,  just  behind  the  external 
angular  process  of  the  frontal,  was  a  puffy  swelling;  when  this  was 
incised,  a  large  fissure  was  found  in  the  skull,  I  an  inch  behind  the 
above  process,  extending  down  behind  the  zygoma.  The  edges  of  this 
were  rough,  and  bulged  slightly  outwards  as  if  by  some  force  from 
within.  At  the  widest  part  of  the  fissure  the  finger  could  feel  the  dura 
.mater — the  bullet  lying  between  it  and  the  bone.    On  extraction  of  the 

*  In  the  Lancet,  August  14,  1886,  is  the  abstract  of  a  case  reported  to  the  Society 
■of  Surgery,  at  Paris,  by  M.  Prengiieber.  Tlie  patient  had  tired  a  revolver  at  tlie  middle 
of  his  temporal  fossa,  the  bullet  lodging  in  his  brain.  For  the  three  days  following 
the  accident  the  surgeon  abstained  from  interference,  as  the  only  symptoms  were  gen- 
,eral  prostration  with  lowering  of  the  temperature.  E[)ileptiform  attacks  having 
occurred  on  the  fourth  and  fifth  day,  the  wound  was  exposed  and  several  bon^'  spicula 
removed,  which  had  penetrated  the  brain.  A  stilet  having  failed  to  detect  the  bullet, 
though  {lassed  along  its  course  to  a  depth  of  five  centimetres,  nothing  else  was  done. 
The  epilei)tiform  seizures  did  not  recur,  and  the  patient  left  the  hospital  at  the  end  of 
.a  month,  without  any  cerebral  complication. 

,t  Lond.  Med.  Times  and  Gaz.,  August  16,  18-56. 


REMOVAL    OF    BULLETS    FROM    THE    BRAIN.  203 

bullet  with  dressing-forceps,  the  dura  mater,  though  much  detached, 
was  found  to  be  uninjured. 

From  the  symptoms  which  followed,  and  from  examination  with  a 
probe,  the  course  of  the  bullet  was  probably  as  follows  :  Entering 
behind  the  angle  of  the  jaw,  it  passed  through  the  pharynx,  then  cleft 
the  palate,  and  ascending  through  the  great  wing  of  the  sphenoid 
external  to  the  external  pter3"goid  plate,  coursed  at  first  upwards 
between  the  dura  mater  and  the  bone,  and  then  dropped,  spent,  into 
the  lower  angle  of  the  fissure. 

On  the  other  hand,  no  one,  in  my  opinion,  would  blame  the  surgeon 
who,  preferring  exploratory  to  expectant  treatment,  endeavors  to 
remove  the  bullet  from  the  brain. 

For  while  the  cases  of  recovery  after'  expectant  treatment  are  few, 
it  is  probal)le  that  out  of  these,  few  as  they  are,  a  considerable  pro- 
portion, if  watched,  Avould  be  found  to  be  incomplete  recoveries.  Thus 
Dr.  Otis  *  writes  of  balls  lodged  within  the  cranial  cavity :  "  Many 
instances  were  reported  of  patients  who  had  survived  the  lodgment  of 
missiles  within  the  skull,  but  few  or  none  resembling  the  cases  reported 
by  Larre}^,  of  balls  encysted  in  the  brain  and  giving  no  inconvenience 
for  years.  It  is,  indeed,  reported  that  some  patients  went  to  duty  with 
balls  lodged  in  the  cerebrum  ;  but  the  diagnostic  details  accompanying 
the  histor}'  of  these  cases  are  not  sufficiently  precise  to  invite  the  fullest 
confidence.  In  most  of  the  cases  in  which  the  evidence  that  the  ball 
remained  within  the  skull  was  conclusive,  either  fistulous  sinuses 
existed,  or  there  was  much  cerebral  disorder,!  or  the  position  of  the 
missile  was  discovered  after  the  patient's  death  at  a  period  remote  from 
the  injury." 

The  evil  results  of  allowing  a  foreign  body  to  remain  in  the  brain 
are  usually  manifested  sooner  or  later,  even  as  long  as  thirteen  years 
after  the  injury.  Inflammation,  slow  or  rapid,  sometimes  involving 
large  portions  of  the  brain-tissue,  or  yellow  softening  are  apt  to  be  set 
up  around  the  foreign  substance,  either  spontaneously,  so  to  say,  or 
from  the  most  trivial  exciting  causes.     The  usual  termination  is  cere- 


*  Med.  and  Surg.  Hist  of  the  War  of  the  Rebellion,  pt.  i.  p.  193. 

f  Dr.  Nancrede  (Intern.  Encycl.  of  Stir g.,  vol.  v.  p.  72)  gives  the  following  important 
abstract  of  a  most  careful  paper  by  Dr.  Wharton  [Phila.  Med.  Times,  1879)  in  which 
316  cases  of  foreign  bodies  lodged  in  tiie  brain  are  analyzed.  Of  these,  160  recovered, 
while  156  proved  fatal.  The  influence  upon  recovery  of  the  removal  or  retention  of  the 
foreign  body  was  most  marked.  Tiie  foreign  body  was  removed  in  106  cases,  72 
recovering,  while  only  34  died.  In  the  remaining  210  no  attempt  at  removal  was 
made,  and  only  88  recovered,  122  dying.  A  further  analysis  shows  that  amongst  those 
cases  classed  as  recoveries,  death  ultimately  took  place  in  ten  at  periods  varying  from 
three  to  ten  years,  and  that  many  of  the  patients  suffered  from  such  after-effects  as 
vertigo,  incapacity  for  physical  exertion,  loss  of  sight  or  hearing,  epilepsy,  and  dete- 
riorated mental  powers. 


204  OPERATIONS    ON    THE    HEAD    AND    NECK. 

bral  abscess,  this  condition  having  l)een  found  in  fifty-three  cases,  in 
which  a  post-mortem  examination  was  obtained.  Apoplexy  is  an 
occasional  cause  of  death,  as  is  pressure  of  the  foreign  body  on  the 
venous  trunks  inducing  ventricular  effusion  and  consequent  com- 
pression of  the  cranial  nerves.  The  probable  explanation  of  those 
cases  in  which  no  symptoms  have  been  present  for  long  periods,  but 
in  which  death  has  rajjiiUy  followed  upon  the  sudden  development 
of  brain  symptoms,  is  that  quoted  by  Wharton  from  Flourens.  This 
observer  found  that  bullets  introduced  into  different  portions 'of  the 
upper  parts  of  the  hemispheres  and  the  cerebellum  gradually  pene- 
trated the  brain  substance,  ultimately  reaching  the  basis  cranii,  the 
bullet  tracks  healing  after  them  (Nancrede,  from  Wharton). 

As  to  the  fatality  of  wounds  of  the  different  portions  of  the  brain, 
58  deaths  took  place  out  of  132  cases  where  the  foreign  body  entered 
through  the  frontal  bone ;  58  wounds  of  the  parietal  showed  27  deaths 
and  31  recoveries.  The  occipital  bone  was  penetrated  23  times,  with 
16  deaths  and  7  recoveries;  the  temj^oral  bones  31  times,  with  12 
deaths  and  19  recoveries  (Nancrede,  from  Wharton). 

The  following  are  interesting  instances  of  successful  operations  for 
the  removal  of  bullets  penetrating  the  brain,  the  one  being  performed 
a  few  hours  after,  and  the  other  not  till  over  three  months  had  elapsed 
since  the  injury  : 

The  patient,*  aged  nineteen,  shot  himself  with  a  pistol  lield  in  con- 
tact with  his  forehead.  About  twelve  hours  afterwards,  when  seen  1)y 
the  surgeon,  he  was  semi-conscious,  aphasic,  with  complete  loss  of 
motion,  without  loss  of  sensation  on  the  right  side  below  the  head. 
Left  side  hypersesthetic.  Pupils  equally  dilated.  P.  100,  T.  101.4°. 
Ether  was  given,  and  under  the  protection  of  copious  irrigations  of 
corrosive  sublimate  solution  (1  in  1000),  the  wound  of  entrance,  nearly 
in  the  centre  of  the  forehead,  was  enlarged,  including  also  the  wound 
in  the  skull.  This  procedure  was  complicated  by  haemorrhage  from 
a  branch  of  the  cerebral  f  artery,  which  w^as  finally  controlled  by  small 
compression-forceps  left  in  situ.  The  track  of  the  ball  through  the 
brain  was  then  probed  by  a  bulb-pointed  X  copper  probe,  and  the  point 
on  the  scalp  noted  at  which  the  probe  would  emerge  if  projected 
through  the  head.     At  this  point  the  cranium  was  exposed  and  tre- 

*  This  case  was  under  the  care  of  Dr.  Fhihrer  {New  York  Med.  Journ.,  Marcli  28, 
1885  ;  Ann.  of  Surg.,  vol.  i.  No.  6,  p.  573).  Ii  is  from  the  latter  tliat  the  above  account 
is  taken.  It  is  to  be  regretted  that  the  site  of  the  posterior  opening,  and  the  way  in 
which  tlie  drainage-tube  was  passed  across  the  brain,  are  not  mentioned. 

f  Probably  tliis  word  should  be  "  meningeal"? 

X  Owing  to  the  great  facility  witii  whicli  an  ordinary  probe  leaves  the  track  of  a 
foreign  body,  and  enters  healthy  brain  substance,  a  bougie  slightly  softened  and  made 
aseptic  is  likely  to  do  less  damage,  if  a  bulb-pointed  probe  is  not  at  liand. 


REMOVAL    OF    BULLETS    FEOM    THE    BRA IX.  205 

phined.  The  trephine-hole  was  enlarged  towards  the  assumed  opening 
of  emergence  of  the  bullet,  and  the  dura  mater  slit  in  the  same  direc- 
tion. Some  effused  blood  and  disintegrated  brain  matter  appearing, 
more  of  the  skull  was  cut  away,  and  the  slit  in  the  dura  mater  pro- 
longed, until  a  gush  of  brain  matter,  and  a  rent  in  the  pia  mater, 
demonstrated  the  point  of  impact  of  the  bullet.  The  probe  was  intro- 
duced through  the  opening  in  the  pia,  and  passed  downwards  towards 
a  point  where  a  feeling  of  resistance  had  previously  l)een  felt  with  the 
tip  of  a  finger  applied  on  the  surface.  At  the  distance  of  an  inch  the 
bullet  was  detected,  and  then  extracted  with  slender-bladed  forceps. 
It  weighed  42  grains.  A  small-sized  rubber  drainage-tube  was  then 
introduced  along  the  track  of  the  ball  through  the  brain,  and  the  pro- 
jecting ends  cut  off  to  within  H  inch  of  the  skull.  Iodoform  dress- 
ings, with  an  external  protective  layer  of  borated  cotton,  were  applied. 
The  after- histor}'  was  one  of  gradual  but  progressive  amendment.  On 
the  sixth  day  the  drainage-tube  was  withdrawn,  and  replaced  by  a 
drain  made  of  four  strands  of  catgut  and  ten  of  horsehair.  On  the 
eighth  day  the  com})ression-forceps  were  found  to  be  loose.  On  the 
thirteenth  the  catgut  had  become  absorbed,  and  four  strands  of 
horsehair  were  withdrawn.  Considerable  cerebral  irritation  followed 
this  proceeding,  and  as  it  seemed  that  the  presence  of  the  remaining 
hairs  were  exciting  further  disturbance,  they  were  all  withdrawn  on 
the  fifteenth  day.  A  hernia  cerebri  had  developed  at  both  cranial 
openings.  On  the  twenty-fifth  day.  the  patient  was  entirely  free  from 
pain,  and  his  temperature,  respiration,  and  pulse  were  all  normal. 
After  the  thirtieth  day,  the  hernia?,  Avhich  up  to  this  time  had  been 
simply  protected  from  irritation,  were  subjected  to  a  slight  continuous 
pressure.  They  gradually  shrank,  and  by  the  end  of  three  weeks  more 
had  disappeared.  By  the  end  of  the  second  month  after  the  operation 
the  posterior  wound  was  completely  cicatrized.  Three  weeks  later  the 
anterior  wound  also  was  healed.  After  leaving  the  hospital  the 
patient  returned  to  work,  a  slight  impairment  of  memory  being  the 
only  apparent  consequence  of  his  wound.  A  severe  blow  accidentally 
made  upon  the  anterior  scar  some  months  after  returning  to  work, 
determined  a  violent  convulsive  attack,  which  recurred  at  the  end  of 
three  weeks.  Bromides  were  freely  given,  and  no  further  recurrence 
had  taken  place  when  the  report  was  made  six  months  later. 

A  Prussian  sergeant*  was  wounded  at  Spicheren,  August  6,  1870, 
by  a  chassepot  bullet  on  the  left  side  of  the  head.  He  was  rendered 
insensible,  and  remained  so  until  August  23,  when  he  recovered  con- 
sciousness.    The  right  side  of  his  body  was  paralyzed.     On  September 

*  Sir  F.  Longmore  {Syst.  of  Sure/.,  vol.  i.  p.  507).  No  reference  is  given  to  this 
most  interesting  case.  Tlie  fragments  of  the  bullet,  with  a  piece  of  bone  fixed  in  the 
larger  portion,  are  in  the  Xetley  Museum,  No.  5G2. 


206  OPEltATIOXS    ox    THE    HEAD    AND    NECK. 

4,  he  had  an  epileptiform  fit.  A  further  examination  of  the  wound 
was  then  made,  and  a  piece  of  bone  and  three  small  fragments  of  lead 
were  discovered  in  the  brain  near  its  surface  and  removed.  The  fits 
continued  several  times  daily,  but  at  the  end  of  September  they  les- 
sened in  frequency  and  the  paralysis  began  to  decrease.  On  October 
2,  Dr.  Junker  took  charge  of  the  patient.  He  was  still  hemiplegic, 
but  able  to  move  his  fingers ;  was  giddy  and  faint  on  trying  to  raise 
his  head,  semi-comatose,  and  had  almost  daily  epileptiform  fits.  His 
memory  was  nearly  lost.  The  appetite  was  good.  A  sinus  led  from 
the  wound,  and  a  moderate  discharge  of  thin  pus  came  through  a 
drainage-tube  inserted  into  it.  On  November  22,  an  elastic  bougie 
was  passed  by  Dr.  Junker  into  the  opening,  and  a  narrow  canal  was 
found  leading  to  the  base  of  the  left  ventricle.  An  electric  probe  being 
introduced  showed  that  metal  was  lying  at  the  bottom,  and  eventually 
two  pieces  of  lead  were  separately  extracted,  together  weighing  275 
grains.  No  more  fits  occurred,  and  the  paralysis  rapidly  disappeared. 
He  now  regained  strength,  but  became  excitable  and  intolerant  of 
society  to  which  he  had  been  previously  indiff'erent.  The  wound 
gradually  healed  by  granulation,  the  drainage-tube  being  dispensed 
with  in  February,  1871.  By  September  he  was  able  to  walk  with  a 
stick,  and  to  read  large  print.  He  was  then  discharged  from  hos- 
pital. He  was  seen  in  September,  1876,  six  years  after  his  wound. 
He  had  married  in  June  of  that  year,  and  was  able  to  keep  the  books 
of  a  large  business.  Sexual  desire  was  defective.  He  had  a  peculiar 
gait  in  walking,  tottering  unless  looking  at  his  feet,  recalling  the 
appearance  of  locomotor  ataxy.  The  motor  and  sensory  powers  of 
the  legs  were,  however,  perfect,  and  tiie  muscles  well  developed. 
The  above  cases  seem  to  admit  of  the  following  deductions : 
The  surgeon  having  decided  that  the  ball  has  entered,  and  that  the 
patient's  condition  admits  of  immediate  exploration,  opens  up  the 
wound  both  in  the  scalp  and  skull  freely.  He  then  tries  to  make  out 
whether  the  bullet  has  broken  into  fragments,  and  if  it  is  between  the 
bone  and  dura  mater  in  the  neighborhood  of  the  wound.  If  the  dura 
mater  is  merely  punctured  by  the  bullet  or  by  a  fragment  of  bone,  the 
puncture  should  be  enlarged  to  allow  of  cleaning  and,  as  far  as  pos- 
sible, draining  this  spot  of  injury  to  the  arachnoid.  If  it  is  decided 
to  explore  the  brain,  this  must  be  done  with  the  utmost  carefulness 
with  a  bougie  or  bullet-pointed  probe  rendered  aseptic.  If  the  use  of 
such  instruments,  the  depth  they  have  passed,  and  perhaj)s  the  con- 
dition of  the  scalp  at  another  part  of  the  head,  indicate  that  the  bullet 
has  almost  traversed  the  brain,  a  counterspot  should  be  chosen  for 
trephining.  The  whole  length  of  the  wound  in  the  brain  should  be 
drained,  if  possible,  and  drainage  should  be  dispensed  with  slowly. 


REMOVAL  OF  BULLETS  FROM  THE  BRAIN.         207 

Strict  attention  should  be  paid  to  keeping  the  wound  as  sweet  as  pos- 
sible. Any  hernia  cerebri  which  may  ajjpear  should  be  submitted  to 
early  gentle  compression  with  pads  of  aseptic  dressings. 

B.  Other  foreign  bodies  besides  bullets  which  may  penetrate  the 
brain  are  knife-points.  These,  with  their  tendency  to  form  cerebral 
abscess,  have  already  been  alluded  to,  p.  161, 

C.  Another  class  of  body  which  may  be  met  with  by  the  surgeon  in 
civil  practice,  is  shown  in  the  following  case  of  Mr.  Couper's.^  A 
house-painter  fell  twelve  feet  from  a  ladder,  impaling  the  right  side 
of  his  skull  on  the  spike  of  an  iron  palisade.  When  brought  into  the 
hospital  there  was  a  clean  cut  wound  three-quarters  of  an  inch  long, 
immediately  under  the  right  ear,  partly  overlapped  by  its  lobule.  In 
this  the  end  of  a  large  rough  piece  of  metal,  corresponding  to  a  freshly 
broken  spike,  could  be  felt,  and  its  direction  could  be  inferred  to  be 
upwards,  inwards,  and  a  little  forwards  from  the  outer  wound,  which 
was  situated  half  an  inch  under  the  external  meatus  between  the  mas- 
toid process  and  the  ramus  of  the  jaw.  There  was  some  bleeding  from 
the  right  ear,  but  no  facial  or  other  paralysis.  The  patient  being  under 
chloroform,  Mr.  Couper  succeeded,  after  much  forcible  wrenching,  in 
extracting  the  iron,  the  head  being  as  far  as  possible  steadied  by  three 
students  and  the  operator's  hand.  During  these  efforts  three  or  four 
ounces  of  blood  oozed  from  the  wound ;  this  haemorrhage  ceased  as 
soon  as  the  iron  was  out,  but  a  small  quantity  of  semi-fluid  brain 
substance  flowed.  Right  facial  paralysis  came  on  two  days  after  the 
injury,  then  delirium,  restlessness,  and  on  the  seventh  day  left  hemi- 
plegia, followed  by  convulsive  attacks,  affecting  the  right  limbs  and 
right  half  of  the  face.  Two  days  later,  or  nine  days  after  the  accident, 
the  patient  died. 

Post-mortem. — No  pus  between  dura  mater  and  bone,  dura  mater 
healthy,  save  for  congestion.  On  opening  it  the  surface  of  the  right 
hemisphere  showed  well-marked  sub-arachnoid  meningitis.  The  pos- 
terior part  of  the  right  middle  cerebral  lobe  had  been  deej^ly  wounded, 
the  brain  substance  at  this  point  softened,  and  streaked  with  pus,  was 
healthy  everywhere  else.  The  spike  had  entered  just  under  the  apex 
of  the  mastoid  process,  traversed  the  internal  ear,  and  driven  several 
irregular  masses  of  petrous  bone  through  the  dura  mater. 

Probably,  in  a  similar  case,  the  careful  use  of  chisel  or  gouge  might 
loosen  the  foreign  body,  while  the  opening  up  of  the  wound  would 
facilitate  drainage,  and  cleansing  the  parts  damaged,  even  as  far  as 
the  brain  itself. 

*  Lond.  Hasp.  Reports,  vol.  ii.     Hutchinson's  Clin.  Surg.,  vol.  i.  p.  91,  pi.  xvii. 


208  OPERATIONS    ON    THE    HEAD    AND    NECK. 


TREPHINING  FRONTAL  SINUSES. 

Prof.  Ogston  *  has  advised  the  use  of  the  trephine  in  cases  of  reten- 
tion of  secretion  and  chronic  inflammation  of  the  lining  membrane  of 
these  sinuses. 

Indications. — Uneasiness,  pain  over  forehead  and  tenderness  on 
firm  pressure,  with  occasional  escape  from  the  nose  of  thick  ])us,  the 
appearance  of  which  is  not  to  be  otherwise  accounted  for. 

The  above  are  due  to  retention  analogous  to  that  causing  empyema 
of  the  antrum.  As  no  probe  can  be  passed  from  l)elow,  when  all 
other  treatment  fails,  the  sinuses  should  be  opened  above,  and  their 
communication  with  the  nose  dilated. 

Opsration. — A  single  vertical  incision  is  made  down  to  the  bone, 
commencing  at  the  root  of  the  nose,  and  extending  upwards  for  an 
inch  and  a  half  over  the  nasal  eminence  of  the  frontal  bone.  The 
periosteum  havmg  been  divided  and  carefully  cleared  back,  a  tre- 
phine, the  size  of  a  sixpence,  is  applied  to  the  middle  line. 

When  the  trephine  has  been  found  to  enter  a  cavity  which  the 
point  of  a  quill  or  a  probe  shows  to  lie  rather  at  the  lower  part  of  the 
crown,  the  disk  is  removed.  If  the  sinuses  are  large,  this  is  readily 
effected,  but  if  they  are  small,  the  disk  must  be  removed  piecemeal, 
with  a  mallet  and  chisel,  until  the  sinuses  are  laid  bare.  The  bleeding 
is  slight. 

The  object  which  now  meets  the  eye  is  the  livid  mucous  membrane 
lining  the  sinuses.  On  opening  it,  it  is  found  thickened,  and  to  con- 
tain mucus  or  muco-pus.  This  being  sponged  away,  the  orifice  in 
the  nose  is  found  f  with  a  probe  or  a  fine  gum-elastic  catheter,  a 
drainage-tube,  about  the  size  of  a  crow-quill,  should  be  slid  down  into 
the  nose,  and  its  upper  end  left  in  the  sinus,  and  the  skin  united  over 
it,  to  secure  union  by  first  intention.;}; 

If,  however,  owing  to  great  thickening  of  the  mucous  membrane, 
foul  caseous  pus,  etc.,  it  is  necessary  to  use  the  sharp  spoon,  and  to 
disinfect  the  recesses  of  the  sinuses  by  syringing  out,  insufflation  with 
aseptic  powder,  or  brushing  over  with  zinc  chloride  or  silver  nitrate 
solutions,  it  will  be  wiser  to  run  the  risk  of  more  tedious  closure  of 
the  o]3ening,  and  to  bring  the  upper  end  of  the  drainage-tube  out  on 
to  the  forehead,  only  partly  closing  the  wound  around. 

In  1886  I  performed  a  similar  operation  in  a  case  of  syphilitic 
necrosis  affecting  the  upper  turbinated  bones,  ethmoid,  and  nasal 
spine  of  the  frontal  bone.     The  frontal  sinuses  being  freely  opened 

*  Med.  Chron.,  vol.  i.  No.  3,  p.  1. 

f  If  the  oj^ening  lie  too  small,  Prof.  Ogston  advii=es  that  it  should  he  enlarged  hy 
thrusting  down  a  trocar  or  any  stout  instrument. 

X  In  one  of  Prof.  Ogston's  cases  a  small  fistula  persisted  for  some  time. 


CEREBRAL    LOCALIZATIOX,  209 

up,  the  necrosed  Lone  was  removed  from  above  and  below,  and  a  larue 
drainage-tube  brought  out  by  the  forehead  and  nose.  A  condition  of 
foetor  and  nuisance  soon  became  one  of  cleanliness  and  comfort,  and 
an  excellent  recovery  ultimately  took  place  with  very  little  deformity. 

It  is  probable  that  analogous  operations  would  be  found  useful  in 
very  obstinate  cases  of  oza^na,  in  which  there  is  evidence  of  the  mis- 
chief having  extended  to  the  frontal  sinuses,  and  in  which,  there- 
fore, other  treatment,  including  Rouge's  operation  (infra),  will  be 
insufficient. 

Ever}'  attention  should  be  paid  to  keeping  the  wounds  as  aseptic  as 
possible,  and  to  preventing  erysipelas.  A  dressing  of  l)oracic  acid 
lint,  wrung  out  of  a  saturate^  solution  of  boracic  acid,  iced  if  needful, 
frequently  renewed,  or  kept  wetted,  will  be  found  efficient. 


CHAPTER  III. 


CEREBRAL    LOCALIZATION    IN    REFERENCE    TO 

OPERATIONS. 

OPERATIONS  ON  THE  BRAIN. 

CEREBRAL  LOCALIZATION  IN  REFERENCE  TO 
OPERATIONS  (Figs.  47,  48,  49). 

Sufficient  cases  are  now  recorded  in  which,  by  attention  being 
paid  to  the  cerebral  motor  centres,  a  lesion  has  been  diagnosed  and 
localized,  and  an  operation  has  saved  or  relieved  the  patient.  It  only, 
requires  more  close  watching  of  head  cases,  more  careful  weighing  of 
signs  and  symptoms,  for  such  instances  to  be  largely  increased. 

Motor  Area. — The  motor  area,  or  that  part  of  the  cortex  in  which 
lesions  cause  interference  with  the  functions,  especially  paralysis  of 
the  limbs  on  the  opposite  side  of  the  body,  lies  beneath  the  anterior 
half  of  the  parietal  bone.  It  may  be  said  to  be  in  form  a  parallelo- 
gram, about  an  inch  wide,  with  its  centre  traversed  obliquely  by  the 
fissure  of  Rolando. 

Speaking  succinctly,  but  perhaps  with  sufficient  accuracy  for 
practical  purposes,  the  centre  of  speech  lies  (on  the  left  side)  at  the 
lower  and  anterior  angle,  or  a  little  below  and  in  front  of  the  area. 
Paralysis  or  convulsions  limited  to  one  lower  extremity  need  the  tre- 
phine at  the  upper  end  of  the  opposite  motor  area.  Paralysis  of  the 
arm  at  the  middle  third,  paralysis  of  the  face  at  the  lower  third. 
Three  applications  of  a  trephine  with  chipping  away  of  bone  will 
expose  it  for  thorough  examination  ;  if  the  paralysis  is  distinct  and 

14 


210 


OPERATIONS    ON    THE    HEAD    AND    NECK. 


limited,  one  or  two  applications  will  probably  suffice  to  find  the 
lesion.  Where  lesions  are  combined  (footnote,  p.  214),  points  inter- 
mediate between  the  respective  centres  must  be  exposed. 

The  following  aids  in  finding  the  above  most  important  fissure  will 
be  found  useful: 

i.  The  upper  end  of  the  fissure  is  found  about  2  inch  behind  a  point 
midway  between  the  roof  of  the  nose  and  the  external  occipital  pro- 
tuberance, the  lower  end  is  about  1  inch  behind  the  bifurcation  of  the 


+  Most  prominent  pan  of  parietal  eminence,  /.r.  Fissure  of  Rolando.  Sy.f.  Sylvian  fi.s.sure. 
Sy.  h.f.  Horizontal  line  of  Sylvian  fissure.  The  ascending  limb  would  start  two  inches  behind 
and  a  little  above  the  external  angular  process,  running  straight  up  for  an  inch  between  the 
letters  a  and/at  Sy.  a.f.  1  and  2fr.f.  First  and  second  frontal  fissures.  1,  2,  3/r.  c.  First,  second, 
and  third  frontal  convolutions.  1  and  2  t.s.f.  First  and  second  temporo-sphenoidal  fissures. 
1,  2,  3  t.  s.  c.  First,  second,  and  third  temporo-sphenoidal  convolutions.    (After  Reid.) 

Sylvian  fissure.  This  bifurcation  corresponds  to  a  point  li  inch 
behind  and  k  inch  above  the  level  of  the  external  angular  process  of 
the  frontal  bone.* 

Mr.  Godlee,  in  a  most  interesting  case  f  of  trephining  for  cerebral 
tumor,  used  the  following  simple  method  of  exposing  the  fissure  of 
Rolando  in  its  middle  third : 


*  Erichsen's  Surgery,  vol.  i.  p.  731 . 

f  An  abstract  of  this  most  helpful  case  is  given  at  p.  216. 


CEREBRAL    LOCALIZATION.  211 

(1.)  A  line  was  drawn  between  the  frontal  and  occipital  pro- 
tuberance. 

(2.)  At  a  right  angle  to  this  a  line  was  drawn  vertically  downwards 
through  the  front  of  the  external  auditory  meatus. 

(3.)  Parallel  to  the  last  a  line  was  drawn  vertically  upwards  at  the 
level  of  the  posterior  border  of  the  mastoid  process,  reaching  the 
longitudinal  line  (1)  about  2  inches  behind  the  second. 

(4.)  From  the  junction  of  the  lines  1  and  3,  one  was  drawn  diagon- 
ally downwards,  reaching  the  second  about  2  inches  above  the  ex- 
ternal auditory  meatus.  This  was  believed  to  represent  the  direction 
of  the  fissure  of  Rolando. 

ii.  Dr.  Reid*  gives  the  following  directions  for  finding  the  fissure  of 
Rolando  (Fig.  47)  :  A  line  is  first  drawn  from  the  root  of  the  nose  to 
the  external  occipital  protuberance,  the  horizontal  limb  of  the  fissure 
of  Sylviusf  is  next  marked  out,  then,  from  a  base-line  running 
through  the  lowest  part  of  the  infra-orbital  margin  and  the  centre  of 
the  external  auditory  meatus,  draw  two  perpendicular  lines  to  the 
top  of  the  cranium,  one  from  the  depression  in  front  of  the  external 
auditory  meatus,  and  another  from  the  posterior  border  of  the  mas- 
toid process.  There  is  then  described  on  the  surface  of  the  head  a 
four-sided  figure  bounded  above  and  below  by  the  lines  for  the  lon- 
gitudinal fissure  and  horizontal  limb  of  the  fissure  of  Sylvius  re- 
spectively, and  in  front  and  behind  by  the  two  perpendicular  lines. 
If  a  diagonal  line  is  now  drawn  from  the  posterior  superior  to  the 
anterior  inferior  angle  of  this  space,  the  line  will  lie  over  the  fissure 
of  Rolando. 

Position  of  the  Chief  Sutures  (Figs.  48  and  49). — After  con- 
sidering the  most  important  part  of  the  brain,  the  motor  area,  which 
lies  under  the  parietal  bone,  it  will  be  well  to  recall  the  landmarks  of 
the  chief  sutures  which  are  met  with  in  that  region.  The  coronal 
suture,  the  anterior  limit  of  the  parietal  bone,  may  thus  be  traced. 
The  point  where  it  leaves  the  sagittal  suture,  the  bregma,  may  be 
found  by  drawing  a  line  from  a  point  just  in  front  of  the  external 
auditory  meatus  straight  upwards  on  to  the  vertex ;  from  this  point 
the  coronal  suture  runs  downwards  and  forwards,  speaking  roughly, 
to  the  middle  of  the  zygomatic  arch,  or,  more  exactly,  to  join  the 

*  Lancet,  September  27,  1884.  From  this  i)aper  Fig.  47,  slightly  altered,  has  been 
taken. 

t  The  fissure  of  Sylvius  (Figs.  47,  48,  49)  is  found  by  drawing  a  line  from  a  point 
\\  inch  behind  the  external  angular  process  of  the  frontal  bone  to  a  point  f  inch  be- 
low the  most  prominent  part  of  the  (larietal  eminence.  Measuring  from  before  back- 
wards, tiie  first  I  incij  of  tliis  line  will  represent  the  main  fissure,  and  the  rest  its 
horizontal  limb.  The  ascending  limb  will  start  two  inciies  behind  and  slightly  above 
the  external  angular  process,  and  runs  vertically  upwards  for  about  an  incli. 


212 


OPERATIONS   ON   THE    HEAD    AND    NECK. 


temporal  part  of  the  great  wing  of  the  sphenoid,  wliich  it  meets  an 
inch  and  a  half  above  the  zygoma,  and  not  quite  an  inch  behind  the 
external  angular  process  of  the  frontal  bone.* 

Under  this  suture  lie  the  posterior  extremity  of  the  tln-ee  frontal 
convolutions  (Fig.  48),  for  the  frontal  lobe  lies  not  only  under  the 

Fig.  48.1- 


The  above  view  of  the  brain  in  situ,  shows  the  rehitions  of  the  surface  convolutions  to  the  re- 
gions of  the  skull.  R,  Fissure  of  Rolando,  separating  the  parietal  from  the  frontal  lobe.  PO, 
Parieto-occipital  fissure  between  the  parietal  and  occipital  lobes.  S,  S,  Fissure  of  .'Sylvius,  separ- 
ating the  temporo-sphenoidal  from  the  frontal  and  paiietal  lobes.  SF,  MF,  IF,  The  superior, 
middle,  and  inferior  frontal  convolutions.  Asc.F,  Ascending  frontal  convolution.  .\sc-.P,  .\s. 
cending  parietal  convolution.  The  outlines  of  the  coronal,  squaraoso-parietal,  and  lambdoidal 
sutures  are  also  seen,    (.\fter  Turner.) 

frontal  bone,  but  extends  backwards  under  the  anterior  part  of  the 
parietal,  the  fissure  of  Rolando,  which  forms  the  posterior  boundary 
of  the  frontal  lobe,  lying  from  Ij  to  2  inches  behind  the  coronal 
suture. 

The  occipito-parietal  or  himhdoldal  auture,  the  posterior  limit  of  the 
parietal  bone,  will  l)e  marked  out  by  a  line  wliich  starts  from  a  point 
21  inches  above  the  external  occii)ital  protuberance,  and  runs  for- 
wards and  downwards  to  its  termination,  wliich  will  be  found  on  a 
level  with  the  zygoma,  11  inches  behind  the  fissure. 

As  the  occipital  lobe  is  not  limited  to  the  upper  portion  of  the  oc- 
cipital bone,  but  extends  forwards  under  cover  of  the  posterior  part 


*  I  liave  pointed  out — "  Middle  Meningeal  Hsemorrha^p,"  Guy's  Hospital  Reports, 
vol.  .xliii.  p.  152,  pi.  iv.  F'ig.  3— hov.'  thin  the  bone  is  in  tlie  vicinity  of  the  coronal 
suture. 

t  The  above  woodcnt  is  taken,  slightly  altered,  from  Prof.  Turner's  Introduction  to 
Human  Anatomy,  part  i.  p.  266. 


CEREBRAL    LOCALIZATION. 


213 


of  the  parietal,  tlie  ])arieto-occi])ital  fissure  lies  about  J  inch  in  front 
of  the  apex  of  the  lambdoid  suture  (Fig.  48). 

The.  squamous  or  squamoso-parietdl  suture  is  not  so  easy  to  mark  out, 
owing  to  the  irregularity  of  its  curve  and  variations.  Its  highest  point 
is  usually  1?  inch  above  the  zygoma  (Fig.  49). 

The  Sylvian  fissure,  which  separates  the  temporo-sphenoidal  from 
the  parietal  lobe,  passes  from  below  obliquely  upwards  and  l)ackwards 
across  the  line  of  this  suture  near  its  middle  (Fig.  49),  the  temporo- 

p-iG.  49.* 


Fiss.  Roland 
Call.Marg.Fisst'/^ 

lllTERPARIETAL    /        ^^'^ 

Fiss 


r, — ^,  VtInf.  Frontal 


The  chief  convolutions  and  fissures  on  the  outer  surface  of  the  brain,  totietlier  with  the  oiat- 
lines  of  the  sutures  and  bones  beneath  which  th(.y  lie.  Diaf);rammatic.  (After  Roberts,  of  Phila 
delphia.) 

sphenoidal  lobe  not  only  lying  under  the  squamous  and  great  wing 
of  the  sphenoid,  but  passing  upwards  under  cover  of  the  lower  part 
of  the  parietal. 

The  following  practical  points  are  given  by  Prof.  Nancrede :  t 
(1.)  Monoplegia  or  spasms  limited  to  one  member,  or  a  portion  of 
one  member,  indicate  limited  lesions.  If  the  lower  limb  be  affected, 
the  upper  portion  of  the  ascending  parietal  (Fig.  49),  with  perhaps 
also  the  corresponding  part  of  the  ascending  frontal,  is  involved.  A 
trephine-crown  must  then  be  applied  about  the  upper  part  of  the 
Rolandic  line. 


*  The  above  woodcut  is  taken  from  Dr.  Roberts's  paper  on  the  '"Operative  Surgery 
of  tlie  Human  Brain,"  Annals  nf  Surgery,  August,  1885,  p.  119. 
t  Internnt.  Encycl.  Surg.,  vol.  v.  p.  90. 


214  OPERATIONS   ON   THE    HEAD    AND    NECK. 

(2.)  With  paralysis  of  the  arm  and  leg,  the  lesion  probably  in- 
volves the  upper  two-thirds  of  the  ascending  convolutions  with  the 
paracentral  lobule.  The  trephine  should  then  be  placed  at  the  upper 
part  of  the  line,  a  little  lower  than  in  the  former  case.  It  may  per- 
haps be  necessary  to  enlarge  the  opening  by  cutting  out  a  circle  lower 
down. 

(3.)  Paralysis  of  the  upper  extremity  alone  probably  indicates  injury 
to  the  middle  third  of  the  ascending  frontal  convolution,  and  the 
trephine  should  be  applied  a  little  in  front  of  the  middle  third  of  the 
fissure  of  Rolando. 

(4.)  Paralysis  of  the  lower  part  of  the  face  points  to  a  lesion  of  the 
inferior  third  of  the  ascending  convolutions,  or  of  the  foot  of  the 
second  frontal. 

(5.)  In  simple  aphasia  the  trephine-crown  should  be  placed  lower 
down  still,  ill  front  of  and  below  the  lower  extremity  of  the  fissure  of 
Rolando. 

(6.)  In  most  cases  many  centres  are  affected,^  and  consequently 
the  surface  to  be  explored  is  much  Uirger.     Thus  : 

With  paralysis  of  both  lower  extremities,  the  summit  of  the  line 
and  the  contiguous  superior  portion  of  the  cranium  must  be  removed. 
With  paralysis  of  one  upper  and  one  lower  extremity  (hemiplegia) 
the  operation  must  be  performed  at  the  middle  and  upper  portion  of 
the  line ;  in  paralysis  of  the  arm  with  facial  palsy,  at  the  inferior  third 
of  the  line,  and  a  little  in  front ;  in  palsy  of  the  upper  extremity  with 
aphasia,  the  opening  should  be  made  below  and  in  front  of  the  line ; 
with  facial  paralysis  and  aphasia,  the  bone  should  be  removed  in 
front  of  the  left  line,  and  below  its  inferior  extremities. 

The  above  statements  from  Dr.  Nancrede,  following  M.  Lucas- 
Championniere,t  are  liable  to  revision  with  advancing  knowledge. 

The  following  location  of  the  chief  cerebral  centres  is  thus  given 
by  M.  Lucas-Championnere.  Loiver  extremity. — Summit  of  the  ascend- 
ing parietal  convolution.  Upper  and  lower  extremity. — Summit  of  the 
ascending  parietal  and  frontal  convolution.  Upper  extremity. — Middle 
portion  of  the  ascending  frontal  convolution.  Upper  extremity  and 
aphasia. — Lower  third  of  the  ascending  frontal  and  foot  of  the  third 
frontal  convolution.  Facial  paralysis. — Lower  third  of  the  ascending 
frontal  and  foot  of  the  second  frontal.  Aphasia. — Foot  of  the  third 
left  frontal. 


*  The  following  combinations  are  those  usually  met  with  (Nancrede,  loc.  supra  cit., 
p.  89) :  Paralysis  of  face  and  aphasia;  aphasia  and  paralysis  of  the  arm ;  paralysis 
of  arm  and  face ;  paralysis  of  the  upper  and  lower  extremities. 

f  La  Trepanation  guidee par  les  Localisations  cirebrales.  Paris:  1878.  These  state- 
ments will  be  found  to  differ  somewhat  from  those  taught  by  Dr.  Ferrier,  p.  218. 


CEREBRAL    LOCALIZATION.  215 

Contraindications  to  Trephining  in  Lesions  of  the  above  Cerebral  Cen- 
tre*— Evidence  of  base-lesions,  e.g.,  paralysis  of  one  or  more  cranial 
nerves,  neuro-retinitis,  Cheyne-Stokes'  respiration.  Also  hemiplegia, 
accompanied  by  marked  anaesthesia,  contraindicates  operation,  as  the 
latter  symptom  points  to  lesions  which  implicate  other  portions  of  the 
encephalon  than  the  motor  area,  and  which  are  too  deeply  seated  to 
be  accessible  to  operative  interference. 

Cerebral  Localization  in  Injury  to  the  Head.— A  typical 
case,  in  which  localization  may  help  the  surgeon  in  trephining, 
would  be  one  in  which  the  injury  is  limited  to  the  cranium,  and  is 
followed  immediately  by  paralysis.  Secondary  or  tardy  paralysis 
may  be  the  result  of  later  inflammatory  processes.* 

M.  Lucas-Championniere  gives  this  interesting  case  : 

A  man  was  found  in  the  street  with  slight  paralysis  ofthe  right  arm, 
but  sensibility  perfect.  There  was  a  slight  superficial  cut  i  inch  long 
over  the  left  parietal  eminence.  Five  or  six  days  later  the  patient  be- 
came stupid  and  unable  to  swallow,  and  convulsions  increasing  in 
violence,  and  involving  all  the  body,  save  the  right  forearm  and  hand, 
set  in.  Suspecting  a  fracture  of  the  inner  table,  M.  Lucas  Champion- 
niere  trephined  at  the  site  of  the  wound,  and  found  a  fine  fissure  just 
in  front  of  this,  there  was  slight  depression  of  the  fragments,  which 
were  wedged  tightly  together.  After  the  operation  the  convulsions 
ceased,  and  a  good  recovery  took  place,  with  use  of  the  right  arm. 

The  fracture  was  proved  by  measurements  to  be  over  the  middle 
and  lower  part  of  the  fissure  of  Rolando,  considerably  in  front  of  the 
scalp  wound. 

This  case  would  seem  to  show  that  in  trephining  for  what  is  believed 
to  be  a  fracture,  it  is  better  to  apply  the  instrument  over  the  centres 
corresponding  to  the  aff"ected  muscles,  rather  than  at  the  site  of  injury, 
e.g.,  a  scalp  wound. 

Convulsions  in  themselves  are  only  an  indication  for  interference 
when  they  are  localized  and  persist,  and  especially  if  they  alternate 
with  paralysis  of  the  same  muscles. 

In  other  cases  the  reverse  course  is  indicated,  and  the  surgeon  must 
be  guided  by  the  seat  of  injury,  and  not  by  any  cortical  lesion.  Thus, 
in  Mr.  West's  case,  alluded  to  in  the  footnote,  p.  185,  the  patient  had 
right  hemiplegia  and  aphasia,  in  addition  to  the  epileptiform  seiz- 
ures, which,  increasing  in  number  and  severity,  reduced  the  girl  almost 
to  a  state  of  idiocy.  Here,  on  the  doctrine  of  localization,  the  trephine 
should  have  been  applied  near  the  lower  end  ofthe  left  fissure  of  Ro- 
lando; Mr.  West,  however,  followed  the  old  rule  of  trephining  over 
the  site  of  injury,  which   was  in  the  frontal  region.      In  this  case 

*  Nancrede,  loc.  supra  cit.,  p.  9L 


216  OPERATIONS    ON    THE    HEAD    AND    NECK. 

though  the  symptoms  were  much  relieved,  this  relief  was  not  due  to 
removal  of  depressed  bone,  for  the  depression  involved  only  the  outer 
tahle.  Dr.  Douglas  Powell's  explanation  seems  here  to  be  the  correct 
one — viz.,  that  uhe  epileptic  attacks  were  not  due  to  a  direct  lesion  of 
the  brain  at  the  seat  of  injury,  but  rather  of  a  reflex  nature,  the 
injured  part  exciting  the  convulsions,  just  as  a  carious  tooth  might 
do  so. 

Cerebral  Localization  in  the  Diagnosis  and  Removal  of 
Cerebral  Tumors, — Amongst  the  cases  which  have  been  published 
there  have  been  none  to  surpass  in  helpfulness,  from  the  completeness 
of  the  details,  and  the  accuracy  of  its  reasoning,  one  of  the  earliest  of 
the  cases  submitted  to  modern  surgery — viz.,  that  trephined  by  Mr. 
Godlee*  for  Dr.  Hughes  Bennett,  in  1884,  an  abstract  of  which  is  given 
below. 

A  man,  aged  twenty-five,  had,  four  years  before,  suffered  from  slight 
concussion  from  a  blow  on  the  left  f  side  of  the  head.  A  year  later 
first  set  in  twitchings  in  the  left  side  of  the  mouth  and  tongue,  par- 
oxysmal and  irregular  in  occurrence.  Some  months  later  fits  began, 
with  loss  of  consciousness  and  general  convulsions.  This  condition 
lasted  two  and  a  half  years  ;  and  six  months  before  admission,  twitch- 
ings of  left  hand,  followed  shortly  by  weakness  of  the  left  fingers, 
hand,  and  forearm,  were  noticed.  For  three  months  these  had  pre- 
vented his  using  his  tools.  During  this  last  period  there  had  been 
twitchings  of  the  left  leg,  which  had  also  been  getting  weak.  There 
was  nothing  abnormal  in  the  skull  or  scalp.  Vision  was  normal,  but 
optic  neuritis  was  present  on  both  sides,  most  marked  on  the  right. 
Hearing  was  less  acute  in  the  right.  There  was  more  complete  paral- 
ysis of  the  left  fingers,  thumb,  and  hand,  the  elbow  movements  were 
very  limited,  those  of  the  shoulder  impaired.  There  was  no  rigidity, 
or  wasting  of  muscles.  The  toes  of  the  left  leg  did  not  clear  the  ground 
in  walking.  There  was  persistent  vomiting  and  retching,  with  attacks 
of  lancinating  headache,  rendering  life  intolerable.  Large  doses  of 
the  iodides  Avere  fruitless. 

An  operation  being  decided  on,  the  motor  area  and  the  diagonal 
line  representing  the  fissures  of  Rolando,  was  mapped  out  by  the  pro- 
ceedings already  given  at  p.  210.  Theoretically,  in  order  to  hit  the 
middle  of  the  fissure  of  Rolando,  the  centre  of  the  trephine  should 
have  been  placed  about  ■>  inch  behind  the  diagonal  line,  and  about  li 
inch  from  the  median  longitudinal  line.  As,  however,  there  was  a 
tender  spot  on  the  scalp  2  inches  anterior  to  this,  the  first  opening 


*  Med.  Chir   Tranx.,  vol.  Ixviii.  p.  244. 

t  Whether  the  glioma  on  the  right  side  of  the  brain  was  due  to  a  blow  f)n  the  left 
side  must  be  uncertain. 


TUMORS    OF    THE    BRAIN.  217 

was  made  (with  a  trei:)hine  1  inch  in  diameter)  hetween  the  two.* 
Tlie  dura  mater  was  normal;  after  a  crucial  incision  was  made  in  it 
the  brain  was  thought  to  bulge  abnormally,  and  to  be  rather  more 
yellow  than  usual,  otherwise  it  was  healthy.  A  second  crown  was  cut 
away,  overlapping  the  first,  external  to  and  slightly  in  front  of  it, and 
the  angles  of  bone  rounded  off  with  a  chisel  and  hammer,  the  brain 
being  protected  with  a  copper  spatula.  These  two  openings  were  then 
joined  by  one  posterior  to  them,  and  the  edges  being  chipped  away,  a 
triangular  aperture  was  left  measuring  2  by  If  inch.  The  dura  mater 
was  opened  and  a  surface  of  brain  exposed  nearl\'  ec{ual  in  size  to 
that  of  the  skull-opening.  Occupying  most  of  this  space  and  crossing 
it  obliquely  from  above  and  behind,  downwards  and  forwards,  was  a 
convolution.  Into  the  centre  of  this  convolution  an  incision  about  I 
inch  in  length  was  made  with  a  scalpel.  From  i  to  i  inch  below  the 
surface  lay  a  transparent,  lobulated,  solid  tumor,  thinly  encapsuled, 
but  quite  isolated  from  the  surrounding  brain  substance.  The  inci- 
sion into  the  cortex  being  prolonged,  the  sides  of  the  growth  were 
easily  separated  by  a  spatula  of  steel,  readily  bent  into  any  shape. 
The  superficial  surface  of  the  growth  being  thus  isolated,  this  portion 
was  removed  with  the  finger ;  as  part  now  broke  away,  the  deeper 
parts  were  eiiucleated  with  a  sharp  spoon,  the  scraping  being  contin- 
ued till  apparently  only  healthy  brain  matter  remained.  This  caused 
rapid  welling  up  of  blood  into  the  cavity,  which  would  have  held  a 
j^igeon's  egg.  Sponge-pressure  failing,  the  haemorrhage  was  finally 
arrested  with  the  electro-cautery.  The  dura  mater  was  drawn  together 
with  sutures,  and  a  drainage-tube  inserted  beneath  it.  Elsewhere  the 
skin  was  brought  accurately  together.  Antiseptic  precautions,  includ- 
ing the  spray,  were  used  throughout.  The  auiesthetic,  chloroform,  was 
taken  well. 

The  wound  was  not  dressed  till  the  third  day,  when  the  discharge 
had  a  distinctly  ])utrefactive  smell :  the  scalp  near  the  wound  was 
somewhat  oedematous.  Tlie  next  day  wet  boracic-acid  dressings  were 
applied,  there  was  hardly  any  trace  of  smell,  but  a  hernia  cerebri  as 
large  as  half  an  orange  was  protruding  through  the  lips  of  the  wound. 
There  were  no  twitchings  of  limbs  or  fiice,  no  headache.  The  patient 
was  bright  and  cheerful,  with  good  appetite.  The  hernia  cerebri  how- 
ever increased,  and  on  the  eighth  day,  having  reached  the  size  of  half 
a  cricket-ball,  was  snipped  away  with  scissors,  the  parts  removed  con- 
sisting chiefly  of  granular  matter  and  clot,  with,  apparently,  little 
true  cerebral  stricture.  The  cut  surface  was  treated  with  a  strong 
solution  of  zinc  chloride  and  iodoform,  and  a  caj)  of  block-tin  applied. 
The  hernia  cerebri  again  increased  somewhat,  but  all  seemed  to  be 

*  The  centre  of  the  opening  was  1}  incli  from  the  midille  line  and  .i  inch  heiiind  a 
line  drawn  vertically  upwards  IVoni  the  meatus  of  the  ear. 


218  OPERATIONS    ON    THE    HEAD    AND    NECK. 

doing  well,  when,  on  the  twenty-first  day,  a  rigor  appeared,  headache 
followed  and  vomiting,  then  restlessness,  sleeplessness,  and  gradual 
sinking  about  four  weeks  after  the  operation. 

At  the  post-mortem  examination  extensive  arachnitis  was  found. 
The  parietal  area  appeared  to  have  fallen  in  ;  in  its  centre  and  occu- 
pying the  position  of  the  fissure  of  Rolando  was  the  wound  in  the 
brain.  The  destruction  of  the  cerebral  cortex  involved  nearly  all  the 
ascending  parietal  convolution,  the  upper  part  of  the  ascending  fron- 
tal, and  the  anterior  third  of  the  supra-marginal  gyrus.  The  extent  of 
softening  around  was  not  great,  but  it  was  difficult  to  tell  this  accu- 
rately, as  the  brain  had  undergone  the  process  of  hardening.  The 
original  growth  was  a  glioma,  of  the  size  of  a  walnut. 

In  commenting  on  the  case,  most  interesting  remarks  are  grouped 
under  the  following  heads:  (1)  Diagnosis.  (2)  Surgical  treatment. 
(3)  Clinical  phenomena  after  the  operation.  (4)  Revelation  of  the 
autopsy  physiologically  and  pathologically  considered. 

These  will  well  repay  most  careful  perusal :  only  the  chief  points 
can  be  given  here. 

(1)  Diagnosis. — A  brain  growth  on  the  right  side  was  diagnosed  in 
this  case  on  the  following  grounds :  Slow  progress,  uncontrollable 
vomiting.  Violent  pains.  Double  optic  neuritis.  It  was  thought  to 
occupy  the  cortex  because  certain  motor  tracts  were  implicated  in 
definite  order,  because  paralysis  was  present  without  Joss  of  sensibility, 
and  above  all  because  of  certain  paroxysmal  seizures  of  local  convul- 
sions occurring  without  loss  of  consciousness,  eminently  suggestive  of 
irritation  of  the  gray  matter. 

The  special  seat  of  the  lesion  was  believed  to  be  in  the  middle  part 
of  the  right  fissure  of  Rolando.  Following  Prof.  Ferrier,  the  motor 
centres  which  govern  the  voluntary  movements  of  the  lips  and  tongue 
are  situated  in  the  lower  portions  of  the  ascending  parietal  and  frontal 
convolutions.  Higher  up,  in  the  same  gyri,  are  the  motor  centres  for 
the  face-muscles.  Occupying  the  middle  and  nearly  all  the  ascending 
parietal  convolution  are  the  centres  of  the  fingers  and  hands.  In  the 
middle  of  the  ascending  frontal  convolution  are  the  centres  for  move- 
ments of  the  arm  and  upper  arm,  including  flexion,  pronation  and 
supination  of  the  forearm.  At  the  upper  and  back  part  of  the 
ascending  parietal  convolution  is  the  centre  for  the  lower  extremity, 
and  at  the  upper  and  anterior  portions  of  the  ascending  frontal  con- 
volution are  the  centres  for  complex  movements  of  both  the  upper  and 
lower  limbs. 

In  this  case  there  was  complete  paralysis  of  the  fingers  and  hand, 
with  inability  to  pronate  and  sujiinate  the  forearm,  there  was  partial 
paresis  of  the  movements  of  the  elbow,  and  weakness  of  those  of  the 
shoulder-joint.     There  was  also  slight  paresis  of  the  leg  and  one  side 


TUMORS    OF    THE    BEAIX.  219 

of  the  face.  Accompan3'ing  all  these  there  were  paroxysmal  convul- 
sions in  all  these  regions,  occurring  either  singly  or  in  definite  order 
one  after  the  other.  These  phenomena  were  to  be  accounted  for  by  an 
extensive  but  not  absolutely  complete  destruction  of  the  motor  centres 
of  the  fingers,  hand  and  forearm,  with  slight  encroachment  on  and 
irritation  of  those  of  the  face,  upper  arm,  and  leg.  A  very  definite 
localization  was  thus  permitted,  and  the  tumor  was  pronounced  to 
have  occupied  the  whole  thickness  of  the  middle  two-fourths  of  the 
ascending  parietal  convolution,  and  a  portion  of  the  adjoining  upper 
half  of  the  ascending  frontal  convolution. 

The  growth  was  proved  to  be  limited  by  the  fact  that  the  centres  of 
the  leg  above,  of  the  face  and  tongue  below,  of  sight  behind,  and  of 
the  movement  of  the  eyeballs  in  front,  were  not  seriously  involved. 
It  could  not  have  exceeded  2  inches  in  diameter,  and  proved  to  be  a 
glioma,  of  about  the  size  of  a  walnut,  lying  obliquely  in  the  fissure  of 
Rolando.  As  to  the  probable  nature  of  the  tumor,  the  age  of  the 
patient,  the  absence  of  syphilis,  and  the  slow  progress,  suggested 
glioma. 

(2)  The  Operation. — In  this  the  advantages  of  the  chisel  and  hammer 
over  Hey's  saw  were  exemplified.  Mr.  Godlee  considers  that  the  use 
of  a  larger  trephine  might  be  advisable  in  similar  cases.  One  convo- 
lution only  being  exposed  during  the  operation,  there  was  at  the  time 
some  question  as  to  whether  it  was  the  ascending  frontal  or  parietal. 
This  doubt  arose  from  the  circumstance  that  in  the  attempt  to  approach 
the  tender  spot  the  theoretical  position  had  been  slightly  departed 
from.  After  death,  however,  it  was  apparent  that  the  convolution 
which  had  been  incised  was  that  in  which  from  the  first  the  disease 
had  been  diagnosed  to  exist — viz.,  the  ascending  parietal.  There  was 
no  external  appearance  of  disease  about  this  part  except  that  it  seemed 
swollen,  less  glossy,  and  less  vascular  than  natural.  An  incision  into 
this  showed  the  morbid  growth  to  be  immediately  under  the  surface, 
and  almost  completely  involving  the  entire  thickness  of  the  cortex. 
In  clearing  away  the  superficial  parts  of  the  growth  a  small  spatula, 
neither  sharp  nor  blunt,  and  so  tempered  that  it  would  keep  any  shape 
given  to  it,  was  found  most  serviceable,  and  much  preferable  to  the  use 
of  the  cautery,  as  this  so  chars  the  parts  as  to  prevent  a  differentiation 
between  healthy  and  diseased  tissues.  It  may  be  questioned  whether 
it  was  advisable  to  arrest  the  hsemorrhage  from  the  interior  of  the 
wound  by  means  of  the  galvano-cautery,  as  the  bleeding  was  not 
severe  and  would  no  doubt  have  become  arrested  by  natural  means. 
The  use  of  this  instrument  appears  to  have  brought  about  the  putre- 
faction which  was  the  cause  of  the  inflammation  and  consequent 
hernia  cerebri.  It  may  be  doubted  if  the  putrefaction  was  ever  com- 
pletely subdued  ;  the  fact  of  the  meningitis  occurring  at  last,  and  that 


220  OPERATIONS    OX    THE    HEAD    AND    NECK. 

of  smell  having  again  become  apparent  after  the  attempt  at  removal 
of  the  second  protrusion,  point  probably  to  a  continued  septic  infec- 
tion. As  to  the  hernia  cerebri,  it  was  remarkable  in  the  first  place 
that  the  discharge  continued  for  so  long  to  be  so  copious  and  so  watery 
as  to  suggest  the  idea  of  its  being  cerebro-spinal  fluid.*  Secondly,  there 
was  a  difficulty  in  shaving  it  off",  owing  to  the  enormous  size  of  its  base 
and  the  danger  of  serious  hemorrhage. 

(3)  Clinical  Phenomena  following  the  Operation. — The  patient  lost  his 
headache,  vomitings,  and  violent  twitchings  in  the  limbs ;  even  the 
double  optic  neuritis  markedly  diminished.  The  only  change  which 
followed  the  operation  was  completion  of  the  paresis  of  the  upper  ex- 
tremity, evidently  due  to  the  unavoidable  destruction  of  the  remaining 
arm-centres  in  the  removal  of  the  tumor.  Coincident  also  with  the 
formation  of  the  hernia  cerebri  came  fresh  symptoms,  in  the  shape  of 
paresis  of  the  left  leg  and  partial  ans^esthesia  of  one-half  of  the  body. 
These  were  probably  due  to  the  effects  of  simple  pressure,  and  pos- 
sibly to  the  subsequent  secondary  softening  of  the  conducting  fibres 
caused  by  it.  On  the  twenty-first  day  the  patient  was  seized  with  a 
rigor,  followed  by  fever,  and  all  the  symptoms  of  meningitis,  from 
which  he  died  a  week  later. 

(4)  Revelations  of  the  Autopsy. — The  brain  was  practicall}^  everywhere 
healthy,  except  over  the  area  injured  by  the  operation,  and  in  the 
membranes  in  the  immediate  neighborhood.  The  meningitis  Was  due 
to  irritating  matter  from  the  interior  of  the  wound  flowing  downwards 
between  the  layers  of  the  arachnoid,  and  accumulating  at  the  base 
of  the  brain.  The  local  inflammation  of  the  wound  had  opened  out 
the  parts,  and  separated  the  adhesions  so  as  to  allow  the  discharge  to 
percolate  into  the  cranial  cavity,  but  not  till  three  weeks  after  the 
operation. 

The  above  most  valuable  paper,  based  upon  the  work  of  practical 
physiologists,  having  served  a  pioneering  purpose,  and  proved  the 
practicabilit}'  of  dealing  with  brain-growths,  has  been  followed  up  by 
other  surgeons.  Amongst  these  Prof.  Horsley's  work  has  been  pre- 
eminent. His  three  successful  cases  brought  before  the  Section  of  Sur- 
gery at  the  Brighton  meeting  of  the  British  Medical  Association,!  in 
which,  guided  by  cerebral  localization,  he  methodically  planned  and 
carried  out  attacks  upon  the  human  brain,  will  repay  the  most  careful 
study.  All  three  patients  suffered  from  epileptic  seizures,  which  in  two 
were  due  to  old  depressed  fractures  received  fifteen  and  eleven  years 

*  Wliether  the  lateral  ventricle  had  been  opened  into,  tlie  post-inorteco  examination 
(lid  not  prove  conclnsively.  There  was  no  collection  of  foreign  matter  in  its  interior; 
at  the  same  time  the  softening  had  extended  close  to  it. 

t  Brit.  Med.  Journ.,  October  9th,  18:56.  A  second  pa;)  m-  will  he  fo-ml  in  the  same 
periodical  for  April  23d,  1887. 


TUMOES    OF    THE    BRAIX.  221 

before  respectively  ;  in  the  third  a  tubercular  tumor  Avas  the  cause,  and 
this  case,  on  account  of  the  exceeding  rarity  of  successful  interference 
in  such  cerebral  cases,  is  much  the  most  interesting  of  the  three. 

A  man,  aged  twenty,  began,  in  January,  1884,  to  have  cramps  in  the 
left  thumb  and  forefinger,  these  consisting  of  clonic  opposition  of  the 
above-named  digits,  occurring  about  twice  a  day  for  three  months. 
The  first  severe  fit  occurred  March,  1884  ;  the  second  in  January,  1885. 
Then  followed  a  series  of  remissions  of  the  twitchings,  until  in  August, 
1885,  commenced  a  series  of  fits  occurring  once  or  twnce  a  Aveek  until 
admission  in  December,  1885.  The  character  of  the  fits  was  nearly 
always  the  same.  They  began  b}'  clonic  spasmodic  opposition  of  the 
left  tliumb  and  forefinger,  the  wrist  next,  and  then  the  elbow  and 
shoulder  w'ere  flexed  clonically,  then  the  face  twitched  and  the 
patient  lost  consciousness.  The  hand  and  eyes  then  turned  to  the  left, 
and  the  left  lower  limb  was  drawn  up.  The  right  lower  limb  w'as  next 
attacked,  and  finally  the  right  upper  limb.  At  frequent  intervals  every 
day  the  patient's  thumb  would  commence  twdtching,  but  the  progress 
of  the  convulsion  could  often  be  arrested  by  stretching  the  thumb  or 
applying  a  ligature.  Sensation  was  not  affected.  There  was  frequently 
severe  headache,  beginning  at  the  occiput  and  shooting  forward,  espe- 
cially to  the  right  parietal  region.  The  optic  disks  were  normal.  It  was 
decided  to  explore  the  junction  of  the  middle  and  lower  thirds  of  the 
ascending  frontal  and  parietal  convolutions,  a  spot  at  which  Prof 
Horslcy  and  Dr.  Beevor  had  shown  that  the  movement  of  opposition 
of  the  thumb  and  finger  could  be  elicited. 

On  June  22,  1886,  the  seat  of  the  lesion  being  determined  by 
measurement,  the  two-inch  trephine  was  applied,  and  on  removing  the 
dura  mater  a  tumor  came  into  view.  By  further  removal  of  bone  the 
mass  to  which  the  duva  mater  was  adherent  was  completely  exposed. 
It  stood  out  about  i  inch  from  the  surface  of  the  brain,  and  was  much 
denser  than  the  brain  substance.  It  appeared  to  be  only  I  inch  bi'oad, 
but  as  the  brain  substance  all  around  it  for  more  than  i  inch  appeared 
dusky  and  livid,  the  part  apparently  diseased  was  all  freely  removed. 
This  was  fully  justified,  since  the  growth  spread  widely  under  the 
cortex.  Before  closing  the  wound  the  centre  of  the  thumb-area  was 
removed  by  a  free  incision.*  Numerous  vessels  were  ligatured.  The 
wound  healed,  and  within  tw^o  months  the  patient  had  regained 
everything,  except  that  the  grasp  of  the  left  hand  was  not  quite  so  good 
as  before. t     There  had  been  no  fits  since  the  operation.     The  tumor 

*  Tliis  detail  Dr.  Hiiglilings  Jackson  and  Prof.  Horsley  had  resolved  to  carrv  out 
in  the  jiossible  event  of  there  being  no  obvious  gross,  organic  disease,  in  order  to  pre- 
vent, as  far  as  possible,  recurrence  of  the  epilepsy. 

t  Dr.  Hughlings  Jackson,  in  the  discussion  on  Prof.  Horsley's  paper,  said  that  it 
was  proved  that  the  "thuiTjb-centre" — i.e.,  that  part  of  the  cortex  in  which  the  most 


222  OPERATIONS   ON    THE    HEAD    AND    NECK. 

was  composed  of  dense  fibrous  tissue,  with  two  caseated  foci,  micro- 
scopical examination  proving  it  to  be  tubercular. 

In  two  recent  papers  on  cerebral  tumors,*  Dr.  Hale  White  draws 
attention  to  the  following  points  which  will  be  of  interest  to  the  sur- 
geon : 

In  a  certain  number  of  cases  of  tumor  of  the  brain  the  bones  of  the 
skull  will  be  found,  as  the  result  of  increased  pressure,  very  light,  thin, 
roughened  like  sand-paper  on  the  inner  surface,  but  without  any  soft- 
ening. If  this  observation  is  confirmed,  it  is  obvious  that  it  incul- 
cates the  need  of  extra  care  in  trephining,  while  it  points  to  the  value 
of  inspecting  carefully  the  inner  surface  of  the  crown  removed. 

Of  a  hundred  cases  of  cerebral  tumor  the  proportions  were  as  fol- 
lows: 

Tubercle, 45 

Glioma, 24 

Glio-sarcoma,  ...........  2 

Sarcoma,  ............  10 

Carcinoma,        ...........  5 

Lymphoma,      ....         .......  1 

Myxoma, 1 

Cyst, 4 

Gumma,   ............  5 

Doubtful, 3 

100 

Of  the  forty-five  cases  of  tubercle,  the  cerebrum  was  affected  in 
twenty-two,  the  cerebellum  in  twenty  cases.  The  growth  was  mul- 
tiple in  nineteen,  and  single  in  twenty-four  cases.  In  all  the  forty- 
five  cases  one  or  more  other  structures  than  the  brain  were  affected. 
Dr.  White  concludes  that  not  more  than  three  tubercular  cases  were 
likely  to  be  benefited  by  operation,  and  even  in  them  the  other  organs 
were  tubercular. 

Of  the  twenty-four  cases  of  glioma,  of  ten  only  could  it  be  said  that 
they  were  not  infiltrating.  The  cerebrum  was  the  seat  of  the  disease 
in  thirteen  cases,  the  cerebellum  in  four.  In  one  case  there  were  mul- 
tiple gliomata  in  the  brain,  and  in  two  others  there  were  growths  in 
other  parts  of  the  body. 

special  movements  of  the  thumb  are  represented — had  been  cut  out,  by  the  fact  that 
while  the  patient  could  move  his  thumb  he  had  lost  the  most  delicate  movements  of 
it.  Even  if  the  fits  recurred,  the  patient  was  well  rid  of  his  tumor;  if  they  did  recur 
Dr.  Hughlings  Jackson  would  advise  removal  of  more  of  the  cortex,  believing  it  better 
to  have  some  permanent  paralysis  than  to  be  subject  to  fits  becoming  universal. 

*  Guy's  Hospital  Lepmts,  1886:  "  On  the  Condition  of  the  Bones  of  the  Skull  and 
the  Dura  Mater  in  Cases  of  Tumor  of  the  Brain  ;"  "  One  Hundred  Cases  of  Cerebral 
Tumor,  with  reference  to  Operative  Treatment,  etc." 


TUMOBS    OF   THE    BRAIN.  223 

Of  the  ten  cases  of  sarcomata  several  affected  the  dura  mater  in 
inaccessible  positions ;  of  the  five  cases  which  attacked  the  brain  only, 
one  alone  could  have  been  removed  with  an}''  prospect  of  success.  Of 
the  remaining  tumors  none  of  the  carcinomata  or  glio-sarcomata  were 
amenable  to  treatment.  Of  the  four  cases  of  cyst  one  could  certainly, 
and  another  possibly,  have  been  operated  upon  ;  the  myxoma  was  and 
the  lymphoma  was  not,  amenable  to  operation,  and  of  the  three 
doubtful  cases,  two  could  have  been  operated  on.  Dr.  White's  sum- 
ming up  is  as  follows  :  "  Thus  we  see  that  out  of  one  hundred  cases 
of  tumor  of  the  brain,  ten  might  certainly  have  been  operated  upon, 
and  four  additional  ones  might  possibly  liave  been,  so  that  in  10  per 
cent,  of  our  cases  we  can  hold  out  some  hope  of  operative  relief  to  our 
patients,  provided  that  a  correct  diagnosis  of  the  position  of  the  growth 
be  made,  even  so  late  as  shortly  before  their  death,  whilst  of  course 
earlier  in  their  histories  many  others  might  have  been  operated  upon 
with  a  good  prospect  of  success." 

As  bearing  upon  the  subject  of  infiltrating  brain-tumors  alluded  to 
above,  attention  may  be  drawn  to  the  following  cases  :* 

In  a  patient,  aged  thirty-two,  headache,  vertigo,  vomiting,  unilateral 
paralysis,  and  atrophy  of  the  optic  nerve  pointed  to  a  growth  within 
the  cranium  ;  the  epileptic  and  epileptiform  seizures  occurring  without 
loss  of  consciousness,  pointed  to  a  cortical  seat  for  the  growth ;  it  was 
evident  that  the  motor  centres  about  the  right  fissure  of  Rolando  must 
be  the  seat,  and  from  the  fact  that  the  face,  arm  and  leg  centres 
apparently  were  affected,  the  middle  portion  was  supposed  with  cer- 
tainty to  be  involved ;  it  having  been  found  that  the  seat  of  sensation 
exists  in  the  parietal  lobes,  the  anaesthesia  of  the  left  half  of  the  face 
indicated  that  the  growth  was  located  in  the  middle  of  the  gyrus  post- 
centralis.  Syphilis  being  excluded  by  history  and  treatment,  three 
buttons  of  bone  were  removed  Avith  the  trephine,  and  under  the  dura 
mater  was  found  a  glioma,  which  protruded  about  i  inch,  and  was 
removed  in  part,  it  being  difficult  to  separate  it  entirely  from  the 
healthy  brain  tissue.  The  symptoms  were  slightly  improved  by  the 
operation,  but  the  patient  died  seven  days  later.  The  author  attributes 
the  unfavorable  result  to  the  fact  that  the  soft  glioma  was  continuous 
with  the  adjoining  brain  tissue,  so  that  its  complete  separation  was 
impossible  without  the  destruction  of  a  large  portion  of  the  cerebrum. 
Had  it  been  a  hard  tumor  that  could  have  been  readily  isolated,  it  is 
very  probable  that  the  patient  would  have  recovered. 

In  a  patient  of  Dr.  Fraser's,t  seized,  soon  after  a  severe  blow  on  the 
left  side  of  the  forehead,  with  aphasia,  vertigo,  and  later  on  with  in- 

*  Dr.  Hirschfelder :  Annals  of  Surr/ery,  vol.  iv.  No.  2,  p.  171 ;  Pacific  Med.  and  Surg. 
Joum.,  April,  1886. 

t  Lancet,  1886,  vol.  i.  p.  398, 


224  OPERATIONS    OX    THE    HEAD    AND    NECK. 

creasing  headache,  and  then  rioht  heniii)legia,  Prof.  Chiene  trephined 
over  the  left  inferior  frontal  convolution.  There  was  free  hsemorrhage 
from  the  middle  meningeal  artery,  which  ceased  when  the  disk  of  bone 
was  removed.  On  opening  the  dura  mater  nothing  abnormal  could 
be  seen.  On  the  chance  of  there  being  dee]>seated  suppuration,  a  very 
fine  cataract-knife  was  introduced  into  the  brain  in  three  directions, 
but  no  pus  found.     Death  took  place  two  days  later. 

The  left  tempero-sphenoidal  lobe  was  swollen  and  decidedly  larger 
than  the  right.  On  section  immediately  through  the  centre  of  the 
trephine-hole,  the  whole  of  the  temporo  sphenoidal  lobe  was  seen  to  be 
occupied  by  a  large  glioma  and  surrounding  softening,  the  tumor  ex- 
tending backwards  as  a  uniform  infiltration  as  far  as  the  limit  of  the 
posterior  horn  of  the  lateral  ventricle.  It  had  invaded  Broca's  convo- 
lution and  tlie  adjacent  parts  of  the  ascending  frontal  and  parietal 
convolutions.  A  small  nodule  of  similar  tumor,  about  the  size  of  a 
cherry,  was  situated  in  the  middle  third  of  the  ascending  parietal  con- 
volution on  the  right  side. 

The  following  ease*  is  of  great  interest  from  the  size  of  the  growth, 
its  less  usual  site,  and  the  complication  of  haemorrhage,  eventually 
fatal. 

The  patient  was  affected  with  cerebral  symptoms  extending  over 
eighteen  months,  consisting  of  left  hemianopsia,  which  could  only  be 
accounted  for  by  a  destructive  lesion  in  the  neighborhood  of  the  gyrus 
cuneus  of  the  right  occipital  lobe,  and  locomotory  disturbances,  which 
appeared  to  be  due  to  the  pressure-effects  of  a  tumor  on  structures 
below  the  tentorium,  and  implied  a  growth  of  considerable  size.  Oper- 
ation having  been  decided  upon,  a  U-shaped  flap  was  raised,  and  a 
1-inch  trephine  applied  at  1  inch  above  the  occipital  protuberance, 
and  the  same  distance  from  the  middle  line,  beyond  the  limits  of  both 
the  longitudinal  and  lateral  sinuses,  and  the  bone  removed  until  an 
oval  opening  2i  by  2h  inches  was  made,  exposing  a  dura  mater  of  a 
deeper  hue  than  normal;  section  of  this  exposed  the  tumor,  the  out- 
lying edges  and  base  of  which  could  not  be  reached  in  si^ite  of  further 
removal  of  the  cranium ;  it  was  therefore  incised  and  some  of  its  soft- 
ened, granular  and  fatty-looking  contents  forced  out.  Its  size  was 
now  somewhat  diminished,  and  the  forefinger  could  be  passed  between 
the  cranium  and  tumor,  and  by  its  aid  the  delicate  cellular  attach- 
ments that  held  the  mass  in  place  were  felt  to  yield  easil}' ;  enucleation 
noAv  became  jiossible,  and  the  base  was  finally  reached ;  by  next 
drawing  the  finger  gently  but  firmly  towards  the  cranial  opening,  the 
tumor  was  torn  nearly  completely  in  two  and  its  outer  half  lifted  out; 

*  "  Eemoval  of  a  Large  Sarcoma,  causing  Hemianopsia,  from  tiie  Occipital  Lobe  of 
the  Brain,"  by  Dr.  Birdsall  and  Dr.  Weir:  Aew  York  Med.  News,  April  16,  1887; 
Annals  of  Surgery,  vol.  vi.  No.  2,  p.  149. 


TUMORS    OF    THE    BRAIX.  225 

then  the  inner  part  was  separated  from  the  falx  with  the  help  of  tlie 
finger-nail  and  withdrawn.  Inspection  of  the  mass  showed  that  the 
tumor  had  heen  entirely  removed,  and  that  its  probable  attachment 
had  been  towards  the  posterior  border  of  the  falx  ;  the  tumor  was  a 
spindle-celled  sarcoma,  weighing  51  ounces,  measuring  31  inches  long, 
by  2J  inches  wide,  and  being  8i  inches  at  its  greater  circumference. 
The  falx  was  crowded  over  towards  the  left,  and  the  tentorium  de- 
pressed ;  two  bleeding  points  were  observed,  one  being  in  the  region 
of  the  straight  sinus,  although  not  free  enough  for  that  vein,  and 
probably  belonging  to  the  pedicle  of  the  growth,  while  the  other  was 
apparently  arterial. '  It  being  found  that  the  haemorrhage  could  be 
checked  by  direct  pressure,  the  cavity  was  packed  with  5  per  cent, 
iodoform  gauze,  not  too  tightly,  as  it  was  assumed  that  the  released 
brain  would  contribute  additional  pressure,  and  the  ends  of  the  strips 
were  allowed,  for  easy  extraction,  to  protrude  from  the  lower  angle  of 
the  scalp  wound  ;  the  dura  was  partly  united  over  the  gauze  by  several 
loose  sutures  instead  of  being  brought  closely  together,  and  the  scalp 
wound  closed  with  catgut  sutures,  a  rubber  drainage-tube  being  intro- 
duced under  the  skin  up  to  the  skull  opening,  and  over  these  subli- 
mated and  iodoform  peat  bags  were  secured  with  gauze  bandages. 
The  patient  soon  showed  S3anptoms  of  haemorrhage,  which  could  not 
be  controlled  by  further  packing,  and  death  ensued  thirteen  hours 
later.  Dr.  Weir,  in  another  case,  would  favor  the  application  of 
haemostatic  forceps  to  the  bleeding  points,  retaining  thein  in  place  for 
twenty-four  or  forty-eight  hours. 

Chief  DifiRculties  and  Dangers  in  Operations  for  the  Re- 
moval of  Cerebral  Tumors.— Amongst  these  are: 

1.  .Suflicient  exposure  of  the  growth. 

Not  only  may  much  bone  require  removal  (as  in  the  case  recorded, 
p.  224},  but  the  patient's  condition,  from  a  tendency  to  coma,  failing 
pulse,  and  respiration, aided  by  the  etfects  of  the  anaesthetic  (p.  154), 
may  seriously  embarrass  the  surgeon  by  cutting  short  tlie  time  need- 
ful for  sufficient  removal  of  the  cranial  bones. 

2.  Haemorrhage. 

This  may  be  met  with  on  division  of  the  dura  mater  from  sinuses- 
or  branches  of  the  middle  meningeal  artery  which  cannot  be  avoided.. 
The  means  of  treating  such  haemorrhage  have  already  been  given  at 
pp.  159,  178.  Far  graver  hiemorrhage  may  have  to  be  encountered 
on  removing  the  tumor  itself,  as  occurred  in  the  cases  at  pp.  217,  224.. 
The  best  means  of  arresting  this  is  probably,  first,  firm  2:)ressure  with, 
an  aseptic  sponge,  followed  by  careful  packing  of  the  cavity  with, 
strips  of  sal  alembroth  or  iodoform  gauze,  the  ends  being  left  long  for 
removal,  then  uniting,  as  closely  as  possible,  the  dura  mater  with 
chromic  gut  sutures,  and  the  scalp  with  silver  sutures  ovex  tiie  gauze,. 

15 


226  OPERATIONS    ON    THE    HEAD    AND    NECK. 

a  drainage  tube  of  adequate  size  having  first  been  adjusted,  with  its 
distal  end  quite  up  into  the  cavity.  These  means  faihng,  Dr.  Weir's 
suggestion  to  leave  Spencer  Wells's  forceps  in  situ,  should  be  tried,  but 
the  frailness  of  the  tissues  on  which  they  hold,  and  the  need  of  keep- 
ing the  patient's  head  absolutely  still  as  long  as  these  forceps  are  in 
position,  are  points  which  will  not  be  lost  sight  of. 

3.  Difficulty  in  detecting  the  growth.* 
This  may  arise  from  several  causes. 

(a.)  The  want  of  distinctness  in  the  growth — in  other  words,  its 
close  resemblance  to  brain  substance.f 

(6.)  By  the  growth  being  overlaid  by  normah  brain  substance  (p. 
217). 

(c.)  By  change  in  the  growth — viz.,  haemorrhage  from  its  thin- 
walled  vessels,  and  later  on  caseation  of  the  coagula,  these  conditions 
being  likely  to  puzzle  the  operator. 

4.  Difficulty  in  isolating  the  growth. 

(1.)  This  may  be  due  to  the  absence  of  a  capsule,  and  thus  to  the 
infiltration  of  the  surrounding  parts.  Now  that  gliomata,  owing  to  the 
operative  attacks  which  will  be  made  upon  them,  are  of  such  practi- 
cal importance  from  a  new  point  of  view,  this  question  of  a  capsule  is 
a  very  weighty  one.  It  seems  to  be  a  disputed  point.  Thus,  in  Dr. 
Bennett's  and  Mr.  Godlee's  case  the  glioma  was  found  to  be  "thinly 
encapsuled,  but  quite  isolated  from  the  surrounding  brain  substance." 
Not  so,  however,  in  the  cases  at  pp.  223,  224.  Indeed,  the  chief 
pathologists  speak  decisively  on  this  point.  Dr.  Fagge  (loc.swpracit.) 
wrote:  The  substance  of  glioma  "is  always  continuous  with  that  of 
the  surrounding  cerebral  tissue,  for  there  is  never  a  capsule,|  as  with 
some  sarcomata.  Indeed,  it  often  assumes  the  form  of  the  part  in 
which  it  grows,  so  that  one  might  imagine  the  corpus  striatum  or  the 
thalamus,  or  some  particular  convolution,  to  have  become  swollen  to 
three  or  four  times  its  usual  size." 

(2.)  Another  source  of  doubt  in  telling  when  a  glioma  not  encapsu- 
lated has  been  isolated,  arises  from  the  fact  that,  as  pointed  out  by  Dr. 
Fagge  (loc.  supra  cit.)^  these  growths,  in  common  with  all  the  less  cir- 
cumscribed form  of  cerebral  tumors,  are  apt  to  set  up  morbid  changes 
in  their  immediate  vicinity,  usually  of  the  nature  of  softening,  partly 
inflammatory,  partly  cedematous. 

*  I  have  confined  myself  here  to  gliomata,  tlie  commonest  of  cerebral  tumors. 

f  "  A  glioma  may  be  of  a  pinkish-red  color,  or  it  may  look  so  exactly  like  the  nor- 
mal brain-substance  that  a  microscope  is  required  to  demonstrate  its  presence." — Dr. 
Fagge,  Medicine,  vol.  i.  p.  523. 

X  The  glioma  "  is  distinguished  by  having  no  capsule,  but  merging  indefinitely  into 
the  tissue  around.  It  is  firm  and  tough,  otherwise  very  like  brain-tissue,  but  more 
pellucid." — Dr.  Wilks  and  Dr.  Moxon,  Path.  Anal.,  p.  239. 


HORSLEY   ON    OPERATIONS    ON   THE    BRAIN.  227 

PROF.  HORSLEY  S  METHOD  OF  OPERATING  ON 
THE  BRAIN. 

Prof.  Horsley,  in  one  of  the  pai:»ers  already  referred  to,*  described 
in  detail  his  method  of  operating  on  the  brain,  of  which  the  chief 
points  are  here  given  in  abstract : 

Preparation  of  the  Patient. — The  da}'  before  the  operation  the  patient's 
head  is  shaved,  washed  with  soft  soap  and  then  ether;  next,  the  posi- 
tion of  the  lesion  is  ascertained  by  iripasurement,  and  marked  on  the 
scalp.  The  head  is  then  covered  with  lint  soaked  in  carbolic  acid  so- 
lution (one  in  twenty),  oil  silk  and  cotton  wool,  being  thus  thoroughly 
carbolized  for  at  least  twelve  hours  before  the  operation.  Finally,  the 
patient  has  the  usual  purgative  administered  the  evening  before,  fol- 
lowed by  an  enema  on  the  morning  of  the  operation. 

Ansesthetic. — A  hypodermic  injection  of  a  quarter  of  a  grain  of  mor- 
phinef  is  given,  and  then  chloroform  is  administered.  The  object  of 
giving  the  morphine  is  twofold,  in  the  first  place  it  allows  of  the  per- 
formance of  a  prolonged  operation,  without  the  necessity  of  giving  a 
large  amount  of  chloroform,  the  amount  actuallv  used  in  an  operation 
lasting  two  hours  being  very  small. 

The  second'  reason  is  perhaps  tlie  more  important,  that  this  drug 
causes  well-marked  contraction  of  the  arterioles  oT  the  central  nervous 
system,  and  that  consequently  an  incision  into  the  brain  is  accom- 
panied by  very  little  oozing,  if  the  patient  be  under  its  influence. 
Prof.  Horsley  has  not  used  ether  in  men,  fearing  that  it  would  pro- 
duce cerebral  excitement;  chloroform,  on  the  contrary,  producing 
well-marked  depression.  If  there  existed  any  heart  complications., 
the  above  theoretical  considerations  would  be  disregarded  in  favor  of 
the  safer  anesthetic.:]: 

Treatment  of  the  WomuL — The  high  mortality  accompanying  tre- 
phining being  largely  due  to  septic  meningitis,  strict  antiseptic  pre- 
cautions, including  the  spray,  will  alone  give  safety. 

Line  of  Incision. — Prof.  Horsley  disapproves  of  the  ordinary  crucial 
incision  as  inconvenient  at  the  time,  as  the  four  flaps  have  to  be  held 
out  of  the  way,  and  later  on  their  point  of  meeting,  a  weak  spot,  prov- 
ing the  formation  of  a  hernia  cerebri.  If,  on  the  contrary,  a  semi- 
lunar flap  be  raised,  it  can  be  simpl}'^  thrown  back  and  requires  no 

*  Brit.  Med.  Journ.,  October  9,  1886,  and  April  23,  1887. 

t  In  one  case,  a  child  of  four,  one-twentieth  of  a  prain  was  found  amply  sufficient. 

X  Attention  is  also  called  to  the  startling  rapidity  with  which  a  patient,  who  has 
roused  up  in  the  middle  of  one  of  these  prolonged  operations,  can  be  sent  off' again,  in 
a  moment,  with  only  a  few  whiffs  of  the  drug,  and  that  thus  it  is  very  easy  to  give  too 
much  in  a  brief  space  of  time.  Prof.  Horsley  expresses  a  strong  opinion  that  this 
sensitiveness  to  the  action  of  the  ansesthetic  is  more  marked  when  the  dura  mater  is 
opened. 


228  OPERATIONS    ON    THE    HEAD    AND    NECK. 

more  holding ;  later  on,  the  advantage  of  raising  such  a  large  flap, 
which  can  be  laid  down  like  the  lid  of  a  box,  will  be  obvious  since, 
being  continuous  throughout,  it  offers  plenty  of  resistance  to  the 
upward-pushing  brain,  which  the  j^oint  of  meeting  of  four  cross-cuts 
can  never  do;  this,  indeed,  on  the  contrary,  favoring  the  very  thing 
one  wishes  to  avoid.  The  following  details  with  reference  to  raising 
the  flap  will  not  be  out  of  place  here:  (1)  All  the  parts  superficial  to 
the  periosteum  must  be  raised  with  the  flaps.  (2)  The  curve  must  be 
a  shallow  arc  to  avoid  cutting  collateral  vessels.  (3)  It  must  be  so 
drawn  as  not  to  divide  the  main  arterial  branches  supplying  that 
part  of  the  scalp.  The  periosteum  should  be  reflected  by  a  crucial 
incision  from  an  area  corresponding  to  the  first  trephine  hole,  and 
subsequently  as  more  bone  is  cut  away. 

Removed  of  the  Bone. — Where  exploration  has  to  be  made,  tlie  more 
raj^id  way  is  to  make  a  couple  of  holes  with  a  2-inch  trephine  at  the 
opposite  extremities  of  the  area  to  be  removed,  then  to  cut  half 
through  the  sides  of  such  an  area  with  a  Hey's  saw,  and,  finally,  to 
complete  the  division  with  a  powerful  bone-forceps.*  Where  it  is 
possible  to  preserve  the  dura  mater  intact,  the  portions  of  bone  re- 
moved should  be  preserved  in  Avarm  aseptic  sponges,  and,  at  the  end 
of  the  operation,  placed  between  the  skin  and  dura  mater,  having 
been  previously  divided  into  small  fragments  as  advised  by  Dr. 
Macewen.f 

Treatment  of  the  Dura  Mater. — This  should  be  incised  round  four-fifths 
of  the  circumference  of  the  area  exposed  at  I  inch  distance  from  the 
edge  of  the  bone,  so  as  to  render  it  possible  to  stitch  the  edges  together 
afterwards.  The  dura  mater  is  best  opened  first  by  incision  with  the 
scalpel,  and  then  by  blunt-pointed  curved  scissors,  great  care  being 
taken  not  to  wound  the  parts  beneath.  The  main  branches  of  the 
middle  meningeal  are  best  secured  by  ligature  before  they  are  divided. 

Treatment  of  the  Brain.X — If  this,  after  incision  of  the  dura  mater, 

*  In  his  second  paper  {Brit.  Med-  Journ  ,  April  23, 1887),  Prof.  Horsley  reconimendf=, 
as  the  most  rapid  method,  first,  taking  out  an  inch  disk  with  a  trephine,  and  ciUtino; 
out  a  piece  of  tlie  size  required  witii  a  circiihir  saw,  mounted  on  a  Bonwill's  snrgical 
engine  (Mayer  &  Meltzer),  the  separation  being  completed  with  very  powerful  bone- 
forceps. 

t  P'or  the  details  of  Dr.  Macewen's  method  the  reader  is  referred  to  p.  102  of  this 
book.  Though  the  vitality  of  the  fragments  lias  invariably  been  perfectly  preserved, 
Prof.  Horsley  has  not,  so  far,  observed  much  ossification  of  the  cicatrix.  Where  a 
large  area  of  bone  lias  been  removed,  a  perforated  celluloid  cap,  light,  but  verj'  strong, 
is  recommended. 

X  Any  of  the  dura  mater  which  is  adherent  to  tlie  tumor  is  usually  much  altered. 
If  the  mischief  is  recent,  tlie  membrane  will  be  simjily  highly  vascular.  In  advanced 
cases  it  may  be  yellowish,  and  in  some  instances,  on  separating  it  from  the  growth 
beneath,  it  is  found  to  be  of  a  dirty-reddish  color.  In  all  cases  where  it  is  adherent 
the  dura  mater  luus',  be  freelv  excised. 


HOESLEY    ON    OPERATIONS    ON   THE    BRAIN.  229 

bulges  very  prominently  into  the  wound,  it  indicates  pathological 
intracranial  tension,  and  probably  a  tumor*  The  next  point  is  the 
color  of  the  brain.  Prof.  Horsley  believes  that  the  existence  of  a 
slightly  yellowish  tinge,  or,  possibly,  the  contrary  condition — viz., 
lividity — will  indicate  a  tumor  beneath  the  cortex  in  the  corona 
radiata.  The  condition  of  the  vessels  and  of  the  peri-vascular  lym- 
phatics should  next  be  investigated,  and  particular  note  taken  of  any 
yellowish-white  patches  in  the  walls  of  the  latter,  indicating  old  mis- 
chief. Alterations  in  the  density  of  the  brain  must  next  be  observed, 
but  it  must  be  remembered  that  cerebral  tumors,  situated  beneath  the 
cortex,  are  scarcely  to  be  detected,  save  by  exploratory  incision. 

In  removing  a  portion  of  the  brain,  or  a  tumor,  the  bleeding  which 
has  been  so  much  dreaded  will  permanently  cease  if  the  wound  be 
plugged  for  a  few  minutes  with  a  piece  of  sponge.  The  value  of  a 
preliminary  injection  of  morphine  has  already  been  alluded  to,  and 
Prof.  Horsley  further  points  out  that,  owing  to  the  fEict  of  the  main 
vessels  remaining  in  the  pia  mater  they  can  be  raised  from  the  brain, 
and  especially  out  of  the  sulci,  so  as  to  allow  of  the  subjacent  brain 
being  removed.  In  incising  the  brain  the  cuts  in  the  cortex  must  be 
made  exactly  vertical  to  the  surface,  and  directed  into  the  corona 
radiata  where  necessary,  in  such  a  manner  as  to  avoid  damage  to  the 
fibres  coming  from  the  portions  of  cortex,  and  surrounding  the  seat 
of  operation.  If  possible,  portions  of  each  centre  should  always  be 
left,  so  that  the  representation  of  its  movements  may  never  be  totally 
destroyed.  A  portion  of  brain  removed  does  not  leave,  as  might  have 
been  supposed,  a  permanent  gap  with  vertical  sides,  for  in  a  very 

*  Dr.  K.  F.  Weir,  of  New  York,  has  published  {Annals  of  Surgery,  June,  1887,  p. 
506)  a  case  of  trephining  for  a  brain-sarcoma,  in  which  abundant  evidence  of  intra- 
cranial tension  was  found,  but  no  tumor.  The  patient  had  been  operated  on  four 
times  for  the  removal  of  a  cervical  sarcoma.  For  about  six  weeks  cramps  in  the  calf 
of  the  left  leg,  with  failure  of  power  in  the  limb,  had  been  noticed,  and  later,  cramps 
and  numbness  in  the  left  hand,  and  frontal  headaclie.  As  the  paralysis  increased,  and 
stupor  rapidly  set  in,  the  skull  was  trephined  at  the  site  of  the  upper  part  of  tlie  right 
fissure  of  Rolando.  On  dividing  the  dura  mater,  which  was  very  tense  and  bulging, 
deeply  congested  brain-substance  projected  above  the  level  of  liie  skull.  A  piece,  half 
as  large  as  a  hen's  egg,  was  excised,  its  substance  being  deeply  pigmented  and  very 
vascular.  The  following  signs  of  improvement  following  on  the  operation  were  attrib- 
uted to  the  diminished  cerebral  tension  — viz.,  disappearance  and  non-recurrence  of  the 
headache  and  cessation  of  the  spasms  of  the  limbs.  The  portion  of  brain  excised 
suggested  from  its  gross  appearance  the  possibility  of  its  being  infiltrated  with  a  .soft, 
sarcomatous  growth,  but  the  microscope  showed  nothing  abnormal.  About  three 
weeks  after  the  operation  paresis  and  analgesia  appeared  more  clearly  on  both  sides, 
and  death  took  place  two  and  a  half  months  after  the  operation.  No  growth  was 
found  in  the  brain  itself,  but  a  mixed-cell  sarcoma,  apparently  originating  in  the  pia 
mater,  sprang  from  the  lower  surface  of  the  left  cerebellar  lobe,  displacing  the  medulla 
forwards  to  the  right,  and  invading  the  fourth  ventricle. 


230  OPERATIONS    OX    THE    HEAD    AND    NECK. 

short  time  the  corona  radiata  forming  the  floor  of  the  pit  hiilges  ahnost 
to  a  level  with  the  surrounding  cortex. 

Closure  of  the  Wound. — All  bleeding  having  stopped,  the  flap  is 
secured  with  medium-sized  silk  and  horsehair  sutures.  Prof.  Horsley 
removes  the  drainage-tube,  which  is  to  be  inserted  at  the  most 
dependent  part  of  the  incision  (as  the  patient  lies  in  bed),  at  the  end 
of  twenty-four  hours,  and  makes  firm  but  gentle  pressure  over  the 
centre  of  the  flap.  The  tube  serves  to  remove  the  steady  oozing  of 
blood  and  serum  from  the  cut  surfaces,  which  takes  place  during  the 
first  twenty-four  hours,  and  its  removal  at  the  end  of  this  time  is 
advised,  in  order  to  allow  of  a  certain  amount  of  tension  of  wound 
exudation  to  occur  within  the  cavity,  this  tension  not  interfering  with 
primary  union  if  kept  within  proper  bounds,  while  it  secures  pressure 
on  the  brain  which  is  tending  to  extrude,  and  serves,  when  the  wound 
is  finally  healed,  to  separate  the  skin  flap  from  the  brain  beneath  by 
a  cushion  of  soft  connective  tissue.  If,  after  the  removal  of  the  tube, 
there  is  much  pain  and  throbbing  in  the  wound,  and  the  union  threat- 
ens to  break  down,  the  edges  must  be  sufficiently  separated  with  a 
probe,  gently  used,  in  the  track  of  the  drainage-tube. 


CHAPTER   IV. 
OPERATIONS  ON  THE  FACE. 

OPERATIONS  ON  THE  FIFTH  NERVE* 

Under  this  heading  will  be  given  the  operative  treatment  of  facial 
neuralgia,  including  neurotomy,  neurectomy  and  nerve-stretching. 
While  the  results  in  none  of  the  three  are  really  permanent,  in  the 
first  they  are  certainly  the  shortest-lived.  It  is,  perhaps,  too  early  to 
estimate  precisely  the  respective  value  of  neurectomy  and  nerve- 
stretching  of  the  fifth  nerve.  In  the  first  place,  no  comparison  can  be 
naade  between  stretching  a  nerve  like  the  sciatic  (one  from  which  most 
of  our  experience  in  the  operation  has  been  derived)  and  the  fifth 
nerve.  In  the  sciatic,  stretching  alone  is  available,  as  the  nerve  is  a 
mixed  one.  Again,  the  course  of  the  two  nerves  is  widely  different. 
The  sciatic  runs  amongst  soft  parts,  and  is  readily  reached  and 
stretched.  The  fifth  nerve  would  be  readily  ruptured  by  anything 
like  the  force  which  is  usually  applied  to  the  sciatic;  furthermore,  it 
runs  in  its  passage  from  the  skull  through  bony  foramina,  and,  in  the 
case  of  two  of  its  divisions,  through  bony  canals  as  well.  In  the  sec- 
ond place,  in  nerve-stretching,  even  more  than  in  neurectomy,  the 


OPERATIONS    ON    THE    FIFTH    NERVE.  231 

published  results  seem  to  me  to  be  unreliable,  cases  having  here  been 
much  too  often  published  without  sufficiently  prolonged  watching. 
At  present,  I  think  the  respective  value  may  be  summed  up  in  some 
such  way  as  this.  It  would  appear  from  Wagner's  *  laborious  collec- 
tion of  135  cases  of  neurectomy,  that  18  remained  cured  after  as  long 
a  period  as  three  years.  I  am  unable  to  find  any  case  of  nerve- 
stretching  reported  as  cured  after  a  longer  period  of  watching  than 
eight  months. t  As  the  relief  after  either  operation  is  usually  not  per- 
manent, the  surgeon  would  l)e  abundantly  justified  who  first  submitted 
his  ]:»atient  to  nerve-stretching,  and  after  a  relapse  gave  him  another 
period  of  relief  by  the  major  operation  of  a  thoroughly  performed 
neurectomy. 

First  Division  of  Fifth  Nerve :  Neurotomy  and  Neu- 
rectomy.— These  two  operations  may  be  considered  together. 

Neurectomy. — Here  the  incision  may  be  made  above  or  below 
the  eyebrow.  The  latter  is  preferable  as  leading  to  less  scar.  The 
supra-orbital  notch  being  made  out]:  by  firm  pressure  when  the 
patient  is  under  the  influence  of  an  anaesthetic,  the  eyebrow  is  drawn 
up  and  the  eyelid  down,  and  an  incision  an  inch  and  a  half  long  is 
made  along  the  supra  orbital  margin,  with  its  centre  opposite  to  the 
notch.  The  skin,  occipito  frontalis,  and  palpebral  ligament  being 
divided,  the  cellular  tissue  is  separated,  the  nerve  found  in  tlie  notch, 
set  free,  drawn  up  with  a  strabismus  hook  and  a  full  inch  removed. 

Neuroiomy, — This  may  be  performed  subcutaneously  or,  as 
above,  by  an  open  wound,  with  antiseptic  precautions.  Neither  are 
comparable  with  neurectomy,  owing  to  the  rapid  union  of  the  nerve. 
The  open  method  needs  no  further  description.  The  subcutaneous 
method  may  be  thus  briefly  described.  The  position  of  the  supra- 
orbital foramen  being  made  certain  of  by  firm  pressure,  a  narrow 
tenotomy  knife  is  entered  to  the  inner  side  of  the  nerve,  and  then 
passed  outwards  horizontally  beneath  the  skin,  till  its  point  has  passed 
beyond  the  nerve.     Its  edge  is  then  turned  towards  the  bone,  and  the 

*  Arch.  J.  Chir.,  Bd.  xi. 

t  For  a  reference  to  the  statistics  of  Halin,  of  Berlin,  quoted  by  Dr.  Ciiandler  in  his 
tabulation  of  cases  {New  York  Med  Record)  and  for  Dr.  Gray's  tables  (Joiirn.  of  Neu- 
rology  and  Psychiatry,  May,  1882),  I  am  indebted  to  a  paper  by  Dr.  G.  R.  Fowler, 
{Anruds  of  Surgery,  vol  iii.  No.  4,  p.  269),  which  for  its  fulness  and  imi)artiality  is  well 
worthy  of  reference. 

X  The  following  hints  of  Mr.  Holden  [Z/undmarfcs,  Medical  and  Surgical,  p.  6)  will 
be  found  useful:  "The  supra-orbital  notch  or  foramen  can  be  felt  about  the  junction 
of  the  inner  with  the  middle  third  of  the  supra-orbital  margin.  From  this  point  a 
perpendicular  line,  drawn  with  a  slight  inclination  outwards,  so  as  to  cross  the  interval 
between  the  two  bicus[)id  teeth  in  both  jaws,  passes  over  the  infra-orbital  and  the 
mental  foramina.  The  direction  of  these  two  lower  foramina  looks  towards  the  angle 
of  the  nose." 


232  OPERATIONS    ON    THE    HEAD    AND    NECK. 

nerve  divided  as  the  knife  is  withdrawn.  This  means  of  performing 
neurotomy  is  said  to  be  preferable  to  tliat  by  open  wound,  inasmuch 
as  it  leaves  less  scar.  Neurectomy,  however,  should  replace  neurot- 
omy, whether  b}'  tlie  sul)Cutaneous  or  o))en  method. 

Second  Division  of  Fifth  Nerve :  Neurotomy,  Neurec- 
tomy and  Nerve-Stretching. — Of  these,  neurectomy  will  alone 
be  described  in  detail.  In  deciding  between  the  only  two  operations 
wdiich  are  of  value,  the  surgeon  is  referred  to  the  remarks  on  neurec- 
tomy and  nerve-stretching  at  p.  231. 

Neurectomy. — Cases  justifying :  epileptiform  neuralgia  resisting 
all  drugs  and  other  treatment,  e.g.,  extraction  of  teeth,  the  continuous 
current,  etc.  Cases  in  which  life  is  a  burden,  where,  owing  to  the  fre- 
quent recurrence  from  the  slightest  touch,  from  a  draught  of  air,  eating 
or  drinking,*  the  patient  is  incapacitated  for  work,  sleepless  and 
emaciating,  and  perhaps  becoming  a  morphia-habitue. 

Doubtful  Cases. — Cases  in  which  the  neuralgia  is  ascending — viz., 
attacking  first  the  inferior  dental,  then  the  superior  maxillary,  and  so 
on,  in  spite  of  operation.  Age  does  not,  if  other  conditions  are  favor- 
able, necessarily  prohibit  the  operation. f 

Operation. — This,  often  known  as  Carnochan's,  has  the  advantage 
of  removing  the  whole  of  the  second  division  of  the  fifth,  together  with 
the  spheno-palatine  ganglion  as  far  back  as  the  foramen  rotundum, 
the  nerve  forming  the  guide  to  the  surgeon  from  the  surface 
backwards. 

Carnochan  (Amer.  Journ.  Med.  ScL,  1858,  p.  136)  looked  upon  the 
removal  of  Meckel's  ganglion  as  the  key  of  the  operation.  Whether 
his  view  was  right  or  no  that  this  body  could  be  likened  to  a  galvanic 
battery,  keeping  up  a  continuous  supply  of  "  morbid  nervous  sensi- 
bility," there  is  no  doubt  that  removal  of  the  nerve  beyond  the  ganglion 
is  strongly  advisable,  as  by  this  step  the  spheno-palatine  branches  to 
the  gums  are  also  removed.  As  pointed  out  Ijy  Dr.  Chavasse  (Med.  Chir. 
Trans.,  vol.  Ixvii.  p.  151)  and  Mr.  Clutton  (St.  Thomases  Hosp.  Repts.,  vol. 
XV.  p.  213)  removal  of  the  nerve  beyond  Meckel's  ganglion  ensures  the 


*  In  a  patient  of  Dr.  Fowler's  (Annals  of  Surgery,  vol.  iii.  No.  4,  p.  800)  "every 
attempt  to  receive  food  on  that  side  of  the  moiitii  was  foUowed  by  exacerbations  of 
pain  of  the  most  frightful  character.  It  was  only  by  lying  npon  the  opposite  side,  and 
having  a  funnel  passed  back  to  the  pharynx,  so  as  to  guide  the  stream  away  from  the 
diseased  side,  that  he  was  enabled  to  take  food  at  all,  and  that  of  a  liquid  character." 

t  Dr.  Miiclean,  of  Detroit,  in  a  discussion  on  "A  Case  of  Excision  of  the  Inferior 
Dental  Nerve  by  Dr.  Mears"  (Trans  Amer.  Surg.  Assoc,  vol.  ii.  p.  48-3),  mentioned 
two  cases  of  men,  aged  seventy-two  and  sixty-nine,  in  the  first  of  whom  he  excised  the 
infra-orbital  and  inferior  dental ;  and  in  the  second,  the  supra-  and  infra-orbital  nerves 
successfully,  the  good  result  having  lasted  six  years  in  the  first  case. 


OPERATIONS    ON    THE    FIFTH    NERVE,  233 

disconnection  of  the  posterior  dental  nerve*  from  the  brain,  which  is 
probably  the  explanation  of  the  success  which  follows  the  operation. 

An  ana?sthetic  being  given,  and  the  parts  shaved  f  and  cleansed,  a 
T-incision  is  made  with  the  horizontal  portion  reaching  from  canthus 
to  canthus  just  below  the  orbit,  and  the  vertical,  one  running  down 
close  to  the  angle  of  the  mouth.  The  flaps  thus  marked  out  being 
reflected  and  all  hannorrhage  stopped,  the  infra-orbital  nerve  is  defined 
by  a  little  dissection,  cut  as  long  as  possible,  and  a  piece  of  silk  tied 
round  it  to  make  it  serve  as  a  guide. 

A  j-inch  trephine  is  then  applied  just  below,  and  including,  the 
infra-orbital  foramen,  so  as  to  remove  the  anterior  wall  of  the  antrum  ; 
next,  the  same  sized  or  a  i-inch  trephine  is  applied  to  the  posterior 
wall  of  this  cavity  so  as  to  expose  the  spheno-niaxillary  fossa.  Free 
and  trouldesome  haemorrhage  must  be  expected  from  the  first  appli- 
cation of  the  trephine,  partly  from  the  vascular  facial  bone, J  partly 
from  the  mucous  membrane  of  the  antrum,  and  in  the  fossa  itself, 
where  the  l)Ieeding  is  always  copious,  from  the  terminal  branches  of 
the  internal  maxillary.  Pressure  with  small  sponges  in  holders  may 
be  relied  u|)on.  The  next  step  is  to  open  up  the  infra-orbital  canal 
with  a  small  chisel  or  strong  scissors — these  last,  or  fine-cutting  pliers, 
being  used  to  enlarge  the  wound  whenever  useful. 

During  the  operation,  if  daylight  be  insufficient,  a  laryngeal  mirror 
and  artificial  light,  or,  better,  an  electric  light,  will  greatly  help  the 
surgeon. 

The  nerve  being  now  Ijrought  into  the  posterior  trephine-aperture, 
it  is  traced  into  the  spheno-maxillary  fossa,  which  it  enters  through 
the  foramen  rotundum.  Being  kept  on  the  stretch  by  means  of  the 
piece  of  silk,  it  is  severed  with  long,  delicate,  curved  scissors  as  far  back 
and  as  near  the  foramen  as  possible.  If  it  is  still  held  by  filaments 
passing  downwards  (spheno-palatine  branches),  these  should  be  also 
divided  with  scissors.  Mr.  Glutton  considers  that  the  total  length  of 
nerve  removed  from  the  infra-orl)ital  foramen  to  the  foramen  rotundum 
should  be  at  least  11  inch,  without  including  any  of  its  branches. 
Iodoform  should  be  dusted  in  at  once,  and  the  wound  plugged  tempo- 
rarily with  carbolized  sponges  sprinkled  with  iodoform.     When  all 


*  In  both  of  Dr.  Chavasse's  cases  the  commencement  of  the  pain  was  invariably- 
referred  to  the  peri[)hery  of  the  posterior  dental  brandies,  and  it  appeared  very  doubt- 
ful if  stretching  would  have  had  any  eflect  on  slender  branches  at  some  distance  from 
the  extension  point.  Both  of  Dr.  Cliavasse's  cases  remained  practically  well  two  years, 
and  a  year  and  a  iialf,  after  the  operation. 

t  In  one  of  Mr.  Clutton's  cases  this  could  not  have  been  borne  before.  Recurrence, 
slight  and  relieved  by  quinine,  ensueil  in  both  of  Mr.  Clutton's  caies  within  the  year. 

X  The  superficial  hfemorrhajje  will  be  all  the  freer  in  proportion  as  the  part  has 
been  recently  submitted  to  blistering,  liniments,  etc. 


234  OPERATIONS    ON    THE    HEAD    AND    NECK. 

hcTuiorrhage  has  stopped  these  are  removed,  and  the  spheno-maxillary 
fossa  and  antrum  are  lightly  plugged  with  aseptic  gau7.e,  or  boric  lint 
and  iodoform.  The  flaps  are  partially  adjusted  with  a  few  points  of 
suture,  leaving  room  for  drainage  and  the  removal  of  the  plugs,*  iodo- 
form dusted  on,  and  boracic-acid  lint  wrung  out  of  the  same  lotion 
iced,  applied  constantly  and  renewed  frequently  for  the  first  few  days. 
Difficulties  which  may  be  Met  with  During  the  Operation. 

1.  Haemorrhage. 

2.  The  nerve  breaking,  or  being  divided  prematurely. 

3.  A  deep  wound,  difficult  to  illuminate,  especially  if  the  antrum  is 
deep  between  the  two  trephine  wounds. 

Of  other  methods  the  following  need  only  be  alluded  to  here : 

Prof  Liicke  of  Strasburg  f  has  operated  three  times  with  satisfactory 
results  by  the  following  method  :  An  incision  is  made  from  above  the 
external  canthus  along  the  zygoma,  the  masseter  divided,  and  the 
zygomatic  arch  then  sawn  through  in  front,  and  fractured  posteriorly. 
This  is  then  turned  up  with  the  temporal  fascia.  By  these  means  the 
spheno-maxillary  fossa  is  reached,  and  the  nerve  cut  at  its  exit  from 
the  skull.  Tne  zygoma  is  then  replaced,  and  the  masseter  stitched 
to  it. 

Prof.  Lossen  of  Heidelberg  J  has  modified  the  above  by  dividing  the 
temporal  fascia  along  the  upper  border  of  the  zygoma,  then,  after  fract- 
uring the  bone,  turning  it  back  with  the  masseter  left  intact.  After 
replacing  the  bone,  the  temporal  fascia  is  stitched  to  it,  and  the  masseter 
is  unable  to  draw  the  fragment  down. 

Braun  (Centr.f.  Chir.,  April  22, 1882)  records  five  cases  of  intractable 
neuralgia  operated  on  successfully  by  the  above  method. 

The  objections  to  the  above  seem  to  be  the  resulting  fixity  of  the  jaw 
from  deep  cicatrices,  the  risks  of  burrowing  suppuration  and  necrosis, 
while,  as  Mr.  Glutton  (loc.  supra  cit.)  points  out,  the  coronoid  process 
and  the  temporal  muscle  are  very  much  in  the  way,  and  even  when 
the  muscle  is  drawn  on  one  side  the  foramen  is  still  hidden  behind  the 
base  of  the  pterygoid  process. 

Prof.  Pancoast  elevates  the  masseter  by  raising  a  square-shaped  flap 
over  the  ramus  of  the  jaw.  The  coronoid  process  being  resected,  the 
internal  maxillary  artery  is  ligatured,  and  the  heads  of  origin  of  the 
external  pterygoid  separated,  thus  exposing  the  foramen  ovale  and  the 
spheno-maxillary  fissure.  At  the  former  the  inferior  dental  can  be 
divided,  and  after  being  exposed  at  the  mental  foramen  which  is  en- 
larged with  a  dental  burr,  the  whole  nerve  can   be  withdrawn.     The 

*  To  be  removed  in  twenty-four  or  forty-eight  lioiirs  according  to  the  amount  of 
nfemorrhage  met  with  during  the  operation, 
t  Chavasse,  loc.  supra  cit.,  p.  152. 
X  Loc.  supra  cit. 


OPERATIONS    ON    THE    FIFTH    NERVE.  235 

infra-orbital  nerve  can  be  hooked  down  as  it  crosses  the  spheno-maxil- 
lary  fissure,  and  released  at  its  exit  on  the  face  in  the  same  way  as  the 
inferior  dental  has  been  at  the  mental  foramen. 

This  operation  would  seem  likel}'  to  have  many  of  those  objections 
already  given. 

After  any  of  these  operations  on  the  fifth  nerve  the  patient  should 
be  strictly  cautioned  to  avoid  exposure  to  any  of  the  causes  of  a  return 
of  his  enemy.     The  cliief  are  given  below  (p.  239 \ 

Operations  on  Third  Division  of  Fifth  Nerve. 

Neurectomy. — American  surgeons  aided,  perhaps,  by  the  per- 
fection of  their  mechanical  dentistry,  have,  in  this  operation  also,  led 
the  way.  The  following  case  gives  well  most  of  the  points  of  the 
operation  : 

Dr.  Mears*  removed  three  inches  of  the  inferior  dental  nerve, 
including  all  that  part  of  it  contained  in  the  canal  and  part  of  it 
beyond  the  mental  foramen.  The  outer  surface  of  the  jaw  Avas  exposed 
by  reflecting  a  flap  raised  by  an  incision  which  reached  from  the 
middle  of  the  posterior  border  of  the  ramus  along  the  horizontal  ramus 
to  a  point  beyond  the  position  of  the  mental  foramen.  A  2-inch  tre- 
phine was  applied  over  the  position  of  the  inferior  dental  foramen,  and 
a  disk  of  the  outer  table  removed.  The  mental  nerve  was  dissected 
to  the  distance  of  ?  inch  beyond  its  point  of  exit  from  the  foramen 
and  divided.  A  dental  burr  attached  to  the  surgical  engine  was  now 
used  to  enlarge  the  mental  foramen  and  release  the  nerve.  Traction 
Avas  made  upon  the  nerve  at  the  point  where  it  was  exposed  by  the 
trephine,  and  it  was  drawn  entire  from  the  canal.  Before  dividing  it 
posteriorly  it  Avas  draAvn  doAvn  so  that  the  division  might  be  made  as 
high  up  as  possible.  The  artery,  which  Avas  torn,  was  tAvisted,  no 
haemorrhage  folloAved.  The  nerve,  AA'hile  in  the  canal,  Avas  found  to  be 
swollen  and  reddened,  and  the  artery  seemed  compressed  and  flattened. 
The  Avound  healed  in  six  days.  The  patient,  save  for  one  or  tAvo  spasms, 
remained  free  from  pain  for  nine  months,  up  to  date. 

Microscopic  examination  of  the  nerve  removed  shoAved  evidence  of 
a  parenchymatous  neuritis — viz.,  degeneration  of  the  nerve  fibres,  and 
thickening  of  the  connective  tissue. 

Nerve-Stretching. — Mr.  Pittsf  gives  two  cases  of  stretching  of  the 
inferior  dental  nerve  for  neuralgia.  For  more  than  a  year  after  the 
operation  these  cases  Avere  free  from  the  slightest  return  of  pain,  then 
relapses  took  place,  but  mildly,  and  the  condition  of  the  patients  still 
remained  much  improved.  The  inferior  dental  nerve  was  found  by  a 
vertical  incision  within  the  mouth,  along  the  inner|  border  of  the  as- 

*  Trans.  Amer.  Surg.  Assoc,  vol.  ii.  p.  469. 
t  St.  Thomas's  Hosp.  Heports,  vol.  xv.,  p.  207. 
I  Anterior? 


236  OPERATIONS    ON    THE    HEAD    AND    NECK. 

cenrling  ramus.  The  soft  parts  being  separated  from  the  bone  with 
an  elevator,  and  the  position  of  entrance  of  the  nerve  being  recognized 
with  the  finger,  the  nerve  was  stretched  with  a  blunt  hook,  this  being 
passed  close  to  the  bone.  While  it  was  thus  easy  to  take  up  the  nerve 
it  was  difficult  not  to  include  the  artery  as  well,  and  this  in  one  case 
caused  free  haemorrhage,  which  was  arrested  by  clamp-forceps  left  on 
for  twenty-four  hours.  Both  patients  suffered  from  swelling  of  the 
throat  and  neck,  as  might  be  expected  from  the  necessary  bruising  of 
soft  parts,  and  the  impossibility  of  satisfactory  drainage.  Several 
months  elapsed  before  complete  mobility  of  the  jaw  was  regained. 
The  amount  of  pull  required  was  not  great,,  and  it  is  advised  to 
stretch  the  nerve  by  a  "  number  of  small  efforts  rather  than  b}^  one 
jerk." 

Intra-buccal  Division. — The  following  case*  is  of  interest  as 
showing  with  what  facilit}^  the  complication  of  hajmorrhage  noticed 
in  the  last  operation  may  occur. 

The  patient  being  etherized,  and  the  mouth  held  open  by  a  gag,  an 
incision  was  made,  extending  from  the  u})per  to  the  lower  jaw,  along 
the  inner  edge  of  the  latter.  The  spine  of  Spix  was  exposed,  and  the 
nerve  seized  with  a  strong  slender  forceps  at  the  point  at  which  it 
enters  the  dental  canal,  and  divided  with  scissors  above  and  below  the 
forceps.  The  small  mass  removed,  however,  rlid  not  plainly  show 
nerve  tissue,  whereupon  a  blunt  hook  with  a  short  curve  was  intro- 
duced two  or  three  times,  until  finally,  when  passed  Avell  back  and 
drawn  forward,  it  seized  a  cord  which  was  supposed  to  be  the  nerve. 
This  was  divided  with  scissors,  M'hen  quite  a  severe  haemorrhage  took 
place,  which  could  only  be  controlled  by  rapidly  packing  the  wound 
with  iodoform  gauze.  The  haemorrhage  recurred  the  same  evening, 
several  ounces  more  being  lost,  but  it  was  checked  by  additional  com- 
pression, the  jaws  being  firmly  bound  together  so  as  to  force  the  com- 
press against  the  wound.  The  gauze  was  removed  from  the  wound 
piecemeal,  the  last  being  taken  away  by  the  tenth  day. 

STRETCHING  THE  FACIAL  NERVE.f 

As  will  be  seen  from  the  remarks  made  below  (p.  238),  it  is  ex- 
tremely doubtful  if  anything  more  than  temporary  relief,  of  a  variable 
duration,  can  be  promised  by  it. 

Operation. — The  following  account  is  taken  from  Mr.  Godlee's 

*  Dr.  R.  F.  Weir,  of  New  York  (Annals  of  Surgery,  -Tune  3,  1887,  p.  504).  Dr.  Weir 
is  inclined  to  think  that  this  hsemorrhage  arose  from  tiie  internal  maxillary. 

t  The  operation  given  below,  that  of  Baum,  is  not,  accurately  speaking,  one  quite 
on  the  face.     It  may,  however,  be  conveniently  considered  here. 


STRETCHING    THE    FACIAL    NERVE.  237 

paper  (Clin.  Sac.  Trans.,  vol.  xiv.  p.  45),  the  method  is  that  of  Baiim.^^ 
An  incision  begun  behind  the  ear,  about  opposite  to  the  meatus,  was 
carried  downwards  and  forwards  to  a  point  immediately  below  the 
lobule,  and  then  prolonged  almost  perpendicularly,  l»ut  slanting  a  lit- 
tle forwards,  nearly  to  the  angle  of  the  jaw.  A  small  transverse  inci- 
sion was  also  made  below  the  pinna.  After  exposing  the  edge  of  the 
sterno-mastoid  and  parotid,  these  structures  were  separated  deeply 
and  pulled  respectively  backwards  and  forwards.  As  soon  as  the 
edge  of  the  digastric  appeared,  the  knife  was  discarded,  and  the  struct- 
ures immediately  above  and  parallel  with  the  upper  border  of  the 
muscle  were  one  after  the  other  pulled  up  with  a  blunt  hook  or  for- 
ceps and  cleaned  with  a  steel  director.  When  the  nerve  was  reached 
and  raised  on  the  hook  the  twitching  at  first  increased,  a  somewhat 
firmer  pull  averted  it  for  a  time,  but  it  began  again  on  relaxing  the 
tension,  a  still  firmer  pull  not  only  stopped  the  twitching  but  caused 
the  right  side  of  the  face  to  pass  into  a  state  of  complete  paralj^sis. 
One  or  two  further  pulls  were  given,  and  the  wound  closed.j  The 
operation  was  antiseptic  throughout.  Healing  was  complete  about 
the  ninth  day.;}; 

The  performance  of  this  operation  is  easy  in  thin  patients,  in  stout 
and  muscular  ones  it  would  be  decidedly  difficult.  In  different  ex- 
periments on  the  dead  subject  the  amount  of  tension  which  the  'nerve 
would  bear  differed  very  much  :  in  some  cases  it  resisted  for  an  appre- 
ciable time  the  strongest  possible  i>ull,  in  others  it  snapped  across 
with  the  greatest  readiness. 

The  line  for  the  nerve  is  exactly  parallel  with  the  upper  border  of 
the  digastric,  and  it  will  be  found  about  half-wa}^  down  that  part  of 
the  mastoid  process  which  is  exposed  in  the  wound — viz.,  the  free 
anterior  )jorder.  The  great  auricular  nerve  will  be  in  part  divided, 
but  as  long  as  the  operator  keeps  in  the  same  plane  as  the  digastric  he 
can  scarcely  wound  any  vessel  of  importance.     The  deep  parts  of  the 


*  The  other  method  is  tliat  of  Ilueter — hy  an  incision  2  inches  lon^  in  front  of  the 
ear,  its  centre  being  opposite  to  the  upfier  part  of  tiie  lobule.  Dr.  Keen  {Annals  of 
Surgery,  July,  1886,  p.  13)  gives  the  following  reasons  for  preferring  that  of  Baum  :  (1) 
The  scar  is  hidden  behind  the  ear,  a  point  of  mnch  importance  in  women,  in  whom 
this  affection  is  not  uncommon  ;  (2)  it  is  less  bloody  ;  (3)  it  inflicts  less  damage  on  the 
parotid ;  (4)  it  reaches  the  nerve  directly  at  its  emergence  from  the  stylo-mastoid  fora- 
men, before  it  has  given  off  any  brandies  except,  perhaps,  the  posterior  auricular. 
Thus  there  is  no  ri.sk,  as  in  Hueter's  method,  of  the  branches  to  the  occipito  frontalis 
and  orbicularis  esca|)ing.  Tiie  above  advantages  outweigh  the  greater  ease  of  Hueter's 
operation. 

t  Adequate  drainage  by  a  tube  or  gut  ami  Iiorsehair  will,  of  course,  be  provided. 

X  The  surgeon  must  be  prepared  for  what  took  place  in  Mr.  Godlee's  case — viz., 
some  troublesome  conjunctivitis  from  the  gaping  of  the  lids,  which  was  relieved  by 
mildly  astringent  coUyria  and  iiolding  up  the  lower  lid  with  plaster. 


238  OPERATIONS    ON    THE    HEAD    AND    NECK. 

wound  are  in  close  proximity  to  the  internal  jugular  vein.  The  only 
vessels  which  should  be  met  with  are,  the  posterior  auricular  vein 
sviperficially,  and  its  artery  more  deeply,  but  a  good  deal  of  haemor- 
rhage may  arise  from  glandular  branches,  and  Mr.  Godlee's  advice  to 
keep  the  wound  in  a  good  light,  well  opened  out  with  retractors  and 
carefully  sponged  dry,  should  be  remembered. 

Points  which  Deserve  Attention. — (1)  Finding  the  nerve.  To 
avoid  needless  injury  and  to  shorten  the  operation.  Dr.  Keen*  found 
the  use  of  a  weak  faradic  current  very  useful.  A  wet  sponge  was  held 
on  the  cheek,  and  a  fine  wire  at  the  other  end  was  applied  to  various 
points  in  the  wound  till  the  nerve  was  found. 

(2)  Mode  of  stretching  the  nerve.  Dr.  Keen  advises  stretching 
from  the  periphery  towards  the  centre.  The  amount  of  force  to  be 
used  he  estimates  at  four  to  five  pounds,  and  that  this  can  best  be 
achieved  empirically,  by  attempting  to  lift  the  head  (six  to  seven 
pounds),  and  abandoning  the  attempt  the  moment  any  fibres  give 
way.  In  other  words  the  stretchings  should  be  as  severe  as  the  integ- 
rity of  the  nerve  will  allow.f 

(3)  Results  of  the  operation.  It  appears  that  while  many  cases 
have  been,  temporarily,  very  much  relieved,  as  a  certain  rule,  when 
the  nerve  recovers  itself  the  spasms  return.  Dr.  Keen  in  the  table  at 
the  end  of  his  paper  gives  two  cases  in  which  the  cure  lasted  much 
longer,  if  indeed  it  may  not  be  called  permanent,  viz.,  Southam's,;!;  in 
which  there  was  absolute  relief  for  five  years,  and  one  under  the  care 
of  Jesas§  in  which  the  cure  had  lasted  two  years  and  eight  months. 
Dr.  Keen's  concluding  words  are  as  follows  :  "  It  would  seem  therefore 
that,  whether  viewed  from  the  point  of  palliation  or  of  cure,  the  opera- 
tion is,  with  our  present  knowledge,  to  be  looked  upon  favorably. 
Further  observations  may  show  its  inutility,  but  when  we  consider 
the  utter  hopelessness  of  improvement,  much  less  recovery,  from  any 
other  means,  relief  by  this  operation,  even  if  temporary,  is  had  at  a 
very  trivial  cost,  and  would  be  welcomed  by  any  sufferer,  while  per- 
manent cure  is  not  impossible." 


*  Loc.  supra  cit.,  p.  13.  In  the  moist  condition  of  the  wound  a  strong  current  will 
produce  muscular  spasm  at  once,  but  a  very  weak  current  will  only  do  so  when  the 
nerve  is  touched. 

f  Two  cases  are  quoted — those  of  Enlenberg  and  Scliiissler — in  the  first  of  which 
the  nerve  was  "  physically  disorganized"  by  the  stretching,  while  in  the  second  the 
nerve  lay  in  a  small  loop  in  the  cavity  of  the  wound ;  yet  in  each  the  paralysis  gradu- 
ally disappeared  and  the  spasms  partially  returned. 

X  Lancet,  August  27,  1881  ;  Ibid.,  April  10,  1886. 

§  IVien.  Med.  Wock,  No.  2,  1884,  and  No.  27,  1887.  It  is  an  interesting  fact  that 
no  paralysis  followed  in  this  case. 


RESTORATION    OF    STENO'S    DUCT.  239 

Mr.  Godleein  a  second  paper*  in  which  he  pubhshed  the  result  of 
his  first  case — after  remaining  for  nine  months  practically  well  the 
convulsions  suddenly  returned  after  a  severe  nervous  shock,  and 
gradually  increased  until  they  regained  all  their  former  intensity — 
sums  up  somewhat  less  ftivorably :  "  In  discussing  the  question  of 
recommending  the  operation  to  a  patient,  we  must  not  forget  that  the 
risk,  with  due  care,  is  almost  nil ;  that  a  certain  immunity  from  the 
trouble  may  be  safely  promised  for  a  time,  and  that  this  period  may 
be  very  considerably  prolonged,  and  while  Southam's  remarkable  case 
remains  completely  well,  there  is  always  the  hope  that  the  relief  may 
be  permanent.  Were  it  not  for  this,  however,  I  am  afraid  that  the 
general  verdict  would  be  that  the  time  has  come  when  this  small  chap- 
ter of  surgical  therapeutics  ....  must  be  closed." 

It  is  of  course  to  be  understood  that  no  patient  would  be  advised  to 
submit  to  the  operation  without  a  tliorough  trial  of  other  remedies, 
short  of  nerve-stretching. 

And  after  submitting  to  stretching  of  the  nerve,  patients  should  be 
most  careful  to  avoid  any  exciting  and  predisposing  causes  of  a  return 
of  their  trouble — viz.,  exposure  to  cold  chills,  sudden  bright  lights, 
nervous  disorder,  mental  worry,  and  living  low. 

RESTORATION  OF  STENO'S  DUOT. 

Where  after  burns,  stabs,  ulcerations,  sloughing,  operations  for  re- 
moval of  growths,  a  most  annoying  salivary  fistula  persists,  the  patient 
suffering  from  disagreeable  hot  dryness  of  the  mouth,  and  from  con- 
stant irritation  and  inflammation  of  the  soft  parts  from  the  dribbling 
of  saliva,  where  previous  measures — e.g.,  collodion  and  heated  wire, 
paring  the  edges — have  failed,  the  surgeon  may  adopt  one  of  the  fol- 
lowing measures : 

(i.)  The  following  will  often  succeed  in  a  recent  case : 
The  opening  into  the  mouth  is  first  found,  or  one  in  its  position 
made,  by  passing  a  fine  silver  probe  from  the  fistula  into  the  mouth.f 
As  soon  as  the  oral  opening  is  found  or  established,  the  probe  is  passed 
from  the  mouth  along  the  duct,  beyond  the  fistula,  up  to  the  gland 
itself.  The  other  end  of  the  probe  is  then  brought  out  of  the  angle  of 
the  mouth,  curved,  and  secured  by  strapping  on  the  cheek,  while  the 

*  Both  Mr.  Godlee's  second  paper  {Clin.  Soc.  Trans.,  vol.  xvi.  p.  220)  and  Dr.  Keen's 
{he.  supra  cit.)  contain  tables,  the  former  giving  thirteen,  the  latter  twenty-one  cases. 
Mr.  Godlee's  case  was  unwilling  to  pnrchase  relief  from  her  complaint  by  submitting  to 
permanent  paralysis  of  the  affected  side  of  her  face,  owing  to  a  dislike  of  the  very  ob- 
vious nature  of  the  deformity. 

t  Close  to  the  projection  of  the  mucous  membrane,  which  usually  denotes  the  posi- 
tion of  the  orifice  of  the  duct,  opposite  to  the  second  upper  molar  tooth. 


240  OPERATIONS    ON    THE    HEAD    AND    NECK. 

fistula  is  kept  as  dry  as  possible,  and  covered  with  collodion,  in  the 
hope  that  it  Avill  close,*  now  that  the  oral  opening  is  re-established. 

Mr.  H.  Morris  (Clin.  Soc.  Trans.,  vol.  xiii.  p.  144)  has  recorded  a  case 
which  he  successfully  treated  on  the  same  lines,  but  with  a  fine  cat- 
gut bougie,  which  is  much  more  easily  worn  than  a  probe.  He  also 
suggests  that  it  would  be  well  if,  during  any  operation  on  the  face  for 
removal  of  a  new  growth,  it  be  found  necessary  to  divide  the  duct,  a 
bougie  should  be  passed  at  once,  and  the  patency  of  the  duct  secured. 

(ii.)  In  cases  of  longer  standing,  w'here  the  duct  is  more  obliterated, 
especially  at  its  narrow  oral  end,  and  the  restoration  is  not  so  easy, 
some  such  operation  as  Dassault's  must  be  performed.  A  fine  trocar 
and  cannula  is  pushed  through  the  cheek  from  the  fistula  forwards 
and  inwards  into  the  mouth,  following,  as  far  as  possible,  the  course 
of  the  duct.  The  trocar  being  withdrawn,  a  small  silk  seton  is  passed 
along  the  cannula ;  this  is  then  taken  out  and  the  two  ends  of  the 
seton,  the  one  projecting  from  the  mouth  and  the  other  from  the  fis- 
tula, are  tied  together;  at  about  the  end  of  three  weeks  (according  to 
the  amount  of  inflammation)  the  seton  is  Avithdrawn,  and  the  sinus 
established  by  it  is  kept  open  by  probe  or  bougie,  as  already  described. 

When  the  patency  of  the  new  duct  is  thoroughly  established,!  the 
external  aperture  may  be  closed  by  collodion  painting,  the  cautery,  or 
paring  the  edges,  according  to  its  size. 

OPERATIVE  TREATMENT  OF  LUPUS. t 

We  owe  to  German  surgeons  our  knowledge  that,  from  the  infecting 
powder  of  lupus  growth,  it  is  impossible,  when  once  it  is  established,  to 
cure  it  by  constitutional  treatment.  A  further  step  has  been  the 
gradual  replacing  of  local  treatment  with  caustics,  or  the  cautery,  by 
the  erasion  method  of  Volkmann  of  Halle. § 

Lupus  is  so  frequently  met  with  in  this  country,  the  deformities 
which  it  produces  are  so  odious,  and  it  is  so  readily  arrested  by  local 
treatment  vigorously  applied  and  energetically  repeated  if  needful, 
that  a  few  practical  remarks  will  be  made  here  on  the  two  chief 
methods  of  using  it — viz.,  erasion  and  scarification. 

Mr.  J.  Hutchinson  thus  compares  the  three  methods  of  local  treat- 
ment (Brit.  Med.  Journ.,  May  1,  1880):  "All  are  very  good,  but  I 
unhesitatingly  prefer  the  last.    If  caustics  are  used,  they  must  be  used 

*  If  ihis  fails,  a  plastic  operation  of  paring  the  edges  and  nniting  tliem  with  numer- 
ons  fishing-gut  sutures  will  probably  be  required. 

t  Mr.  Erichsen  {Surg.,  vol.  ii.  p.  557)  suggests  the  passage  of  a  piece  of  latninaria 
tent  if  the  sinus  shows  much  tendency  to  close. 

J  The  above  account,  while  introduced  here  from  the  greater  frequency  of  lupus  in 
the  face,  is,  of  course,  applicable  to  the  disease  elsewhere. 

g  Germ.  Clin.  Lect.,  Syd.  Soc.  TransL,  p.  97. 


OPERATIVE  TREATMENT  OF  LUPUS.  241 

very  freely.  I  liave  repeatedly  seen  a  patch  wholly  cured  by  a  single 
dressing  with  chloride  of  zinc  or  acid  nitrate  of  mercury.  As  a  rule, 
these  remedies  are  used  too  timidl}'  or  without  sufficient  painstaking. 
They  give  more  pain  than  the  actual  cautery,  but  their  sores  granu- 
late better  and  heal  more  quickly.  The  actual  cautery  is  compara- 
tively painless,  can  be  easily  limited,  and  at  the  same  time  made  to 
act  deeply.  It  is  very  efficient,  but  its  burns  are  somewhat  slow  to 
heal.  The  erasion  treatment  appears  to  give  less  pain,  to  be  very 
efficient,  and  to  leave  a  sore  which  heals  rapidly  and  soundly." 

Before  speaking  in  detail  of  these  methods  it  will  be  well  to  say  a 
few  words  about  the  chief  forms  of  lupus,  and  to  which  of  these 
erasion  or  scarification  is  best  suited. 

I  think  that  for  the  purpose  of  treatment  the  surgeon  should  keep 
two  great  types  before  his  mind.  In  one  of  these  the  lupus  deposit 
takes  the  shape  of  more  or  less  localized  nodules,  tubercles,  or  nests, 
reddish  or  yellowish  pink,  often  quasi-gelatinous,  and  prone  to  attack 
the  cheeks  near  the  junction  of  the  alae  and  the  upper  lip.  In  the 
other  the  lupus  deposit  is  much  more  diffused,  usually,  too,  more  super- 
ficial and  less  inclined  to  form  nodules  or  nests.  This  t,ype  is  met 
with  both  on  cheeks  and  nose,  but  is  best  seen  on  the  latter.  It  is,  in 
my  experience,  much  the  most  frequently  met  with  form  in  the  sur- 
gical  wards  of  a  London  hospitaj,  and  is  the  one  most  frequently 
responsible  for  marring  the  above  important  feature  in  young  patients, 
usually  girls.  This  is  the  lupus  seborrhagicus  of  Prof.  Volkmann,^ 
the  seborrhcea  being  of  secondary  importance,  the  essential  point  being 
the  fine-cell  lupus  infiltration  of  the  cutis,  which  develops  most  freely 
in  the  neighborhood  of  the  sebaceous  glands,  in  which  the  cheeks  and 
nose  are  so  rich,  and  gives  rise  to  an  increased  secretion  on  their  part. 

Erasion. — This  is  most  strongly  indicated  in  both  the  above  forms 
of  lupus,  whether  localized  or  diffused.  The  best  instruments  are 
sharp  spoons,  with  oval  ends  of  varying  size,  or  hoes ;  whatever  instru- 
ment is  used  should  be  of  steel,  the  silver  scoops  supplied  in  dressing- 
cases  being  inefficient.     Where  the  lupus  deposit  is  of  any  size  it 

*  Prof.  Volkinann  (loc.  supra  cil.,  j).  105)  gives  the  following  life-like  description  of 
this  form:  Irregular,  reddish-looking  patches  n^et  with  on  the  cheeks  and  nose,  often 
covered  with  "  dirty-looking  thin  crusts,  which  are  distinctly  fatty  to  the  touch.  They 
consist,  in  fact,  of  nothing  further  than  an  excessive  secretion  from  the  sebaceous 
glands  of  the  skin  mixed  with  epidermis  cells.  When  we  have  succeede<l,  with  great 
difficulty,  in  scraping  off  this  fatty  layer  with  the  knife,  the  underlying  skin  appears 
red,  sore,  and  as  if  studded  with  fine  warts.  But  if  you  examine  these  warty  points 
more  closely  with  a  glass,  you  see  that  it  is  by  no  means  a  question  of  papillary  eleva- 
lions,  but  of  a  large  number  of  fine  holes,  which,  being  closely  adjacent  to  each  other, 
produce  the  warty  ap[)earance.  These  holes  are  the  enlarged  openings  of  the  seba^ 
ceous  ducts,  and  you  can  also  see  on  peeling  oft'  single  fatty  crusts  how  a  line  prolon» 
gation  of  the  latter  becomes  detached  from  each  small  opening." 

16 


242  OPERATIONS   OX   THE    HEAD    AND    NECK. 

slioiild  be  deliberately  and  tborougbly  scraped  out,  tbe  instrument 
being  carried  most  painstakingly  botb  over  the  surface  and  around 
the  edges.  Where  the  deposits  are  more  minute  they  must  l)e  as 
carefully  picked  out.  The  surgeon  need  not  fear  removing  too  much, 
as  long  as  lie  keeps  to  jiarts  which  yield  to  a  scoop  which  will  never 
remove  sound,  and  only  with  difficulty,  partly  sound,  tissues.* 

Scarification. — This  is  only  useful  in  the  more  diffuse  forms,  and 
is  to  be  employed  in  two  ways,  (a)  Linear.  With  a  fine  tind  very 
sharp  scalpel  the  surgeon  makes  scores  of  fine  delicate  cuts,  parallel 
with  each  other,  through  the  diffuse  lupoid  deposit,  crossing  these 
again  with  similar  delicate  incisions  at  a  right  angle  to  the  first. f  All 
these  must  be  made  quickly  and  with  a  light  hand,  and  care  must  be 
taken,  as  far  as  possible,  not  to  let  them  run  into  each  other.  The 
bleeding  is  extremely  free,  but  is  readily  arrested  by  carefully  main- 
tained pressure. 

(6)  Punctiform.  Here  hundreds,  may  be,  of  punctures  are  made 
in  the  diffused  lupoid  deposit,  a  delicate  hand  being  again  required, 
and  a  fine  sharp  scalpel  point  or  a  large  needle  being  used.  In  this 
case,  also,  every  pains  must  be  taken  to  place  the.  punctures  equi- 
distantly.  After  arresting  the  bleeding  the  surgeon  looks  carefully 
over  the  patch  ;  if  at  any  spots  his  incisions  or  punctures  are  crowded 
together  with  intervening  places  but  little  touched,  he  again  goes  over 
his  ground  carefully. 

If,  after  the  completion  of  these  ojoerations,  the  tissues  appear  tal- 
lowy, or  whitish,  there  need  be  no  fear  of  gangrene,  the  parts  being 
far  too  well  supplied  with  blood.  Prof.  Volkmann,  after  using  the 
above  methods,  wipes  the  parts  over  with  a  stick  of  silver  nitrate  and 
applies  dry  lint.  I  prefer  to  use  iodoform  gauze  at  first  to  the  bleed- 
ing surface,  the  gauze  being  washed  off  with  Avarm  Avater  in  about 
forty-eight  hours,  when  iodoform  ointment  or  lead  lotion  may  be 
made  use  of. 

An  anaesthetic  should  always  be  given,  as  the  pain  involved  is  not 
slight.J     Repetitions  may  be,  and  often  are,  required  in  severe  cases, 

*  As  pointed  out  by  Prof.  Volkmann  (loc.  supra  cit,  p.  114)  in  ciises  of  lupoid  ulcer- 
ation.s  of  longer  standing,  an  almost  fibroid  tissue  becomes  exposed  after  the  diseased 
parts  have  been  scraped  off,  a  condition  which  is  to  be  regarded  as  the  expressi(m  of 
reaction  in  the  neighborhood. 

t  No  scarring  need  be  feared  from  either  form  of  scarification.  After  three  weeks 
have  elapsed  the  above  incisions,  however  nimierons,  if  done  with  proper  delicacy, 
can  only  be  detected  by  looking  for  them  very  closely.  In  tiiree  months  it  usually 
requires  a  lens  to  find  them. 

X  Dr.  Balmanno  Squire  recommends  {Brit.  Med.  Journ.,  May  ],  1880)  the  freezing 
the  skin  with  ether  spray.  This  so  entirely  alters  the  feel  of  parts  that  I  have  not 
nsed  it.  Cocaine  may  perhaps  be  useful  in  the  lighter  cases.  For  rendering  scarifica- 
tion expeditious  and  precise,  Dr.  Squire  has  devised  a  multiple  linear  scarifier.     This 


OPERATIVE  TREATMENT  OF  RODENT  ULCER.        243 

two  or  three  times,  at  intervals  of  three  weeks  or  more,  or  whenever 
minute  reddish  specks  appear  and  grow  arcnnd  the  original  disease, 
or  when  the  scar,  though  not  again  ulcerating,  remains  obstinately 
dark  bluish -red. 

The  object  of  scarification  is,  of  course,  to  obliterate  tlie  lupoid 
tissue  by  the  formation  of  scar  tissue. 

Where  the  nose  is  affected,  the  inner  aspect  of  the  orifices  should  be 
examined  in  case  the  mucous  membrane  is  invaded. 

OPERATIVE  TREATMENT  OF  RODENT  ULCER. 

Owing  to  the  great  frequency  of  this  disease  on  the  face,  the  follow- 
ing remarks  are  inserted  here  : 

Some  Points  of  Practical  Importance. 

i.  Propriety  of  Operation. — In  this  form  of  malignant  disease, 
owing  to  its  extremely  slow  j)rogress,  its  very  long  connection  with 
some  well-known  flat-to}iped  wart,  patients  sometimes  kee])  on  defer- 
ring the  operation  till  their  age  and  the  extent  of  the  ulcer  cause  some 
difficulty  in  urging  or  advising  an  operation. 

The  following  may  help  in  forming  a  decision:  (1)  The  extent, 
depth,  and  site  of  the  ulcer.  A  case  of  moderate  severity — say  of  the 
size  of  half  a  crown — may  nearly  always  be  submitted  to  operation. 
But  the  difficulty  of  deciding  Avill  be  much  greater  in  cases  wdiich  in- 
volve extensively  the  nose,  orbit,  and  eye  as  well,  perhaps,  especially 
if  the  bones  on  the  delicate  inner  wall  are  much  involved ;  in  the 
rarer  cases  in  which  orbit,  nose,  and  mouth  are  thrown  into  one 
hideous  chasm,*  and  those  cases,  also  rare,  in  which  the  ulceration 
extends  very  widely,  though  superficially,  over  the  side  of  the  head 
and  face,  involving  forehead,  temple,  and  parotid  region.!  (2)  In  all 
cases  of  severity  the  following  should  be  carefully  considered — viz., 
the  real  agej  of  the  patient — i.e.,  the  age  not  reckoned  by  years  alone 

instrument  (Weiss)  is  most  useful  in  port-wine  stains,  though  I  prefer  fine,  very  keen 
scalpels,  which  will  suffice  both  for  linear  and  pnnctiform  scarification. 

*  As  in  Figs.  '1  to  6  at  the  end  of  Mr.  Moore's  work  on  Rodent  Ulcer. 

t  Mr.  Moore  {loc  supra  cit.,  Fig.  9)  shows  one  of  thc^e  superficial  but  vast  rodent 
ulcers;  and  his  cases  vi.  and  vii  show  the  exceeding  difficulty,  if  not  impossibility,  of 
completely  curing  them,  even  in  hands  as  experienced  as  his.  He  thought  (p.  o8)  that 
the  firmness  of  the  skull  presented  a  mechanical  obstacle  to  the  complete  healing  of 
these  large  sores.  Mr.  Hutchinson  (Clin.  Surg.,  vol.  ii.  pi.  65)  points  out  that  this  ex- 
tensive form  may  be  very  superficial  for  a  longtime,  may  even  cicatrize  with  tolerable 
soundness,  but  that,  sooner  or  later,  a  stage  ol' deep  growth  and  rapid  progress  is  almost 
certain. 

X  Sir  James  Paget's  words  on  the  risks  of  operations  in  old  people  (Clin.  Led.,  p. 
6)  may  be  quoted  here:  "They  that  are  fat  and  bloated,  pale,  with  soft  textures,  flab- 
bid,  torpid,  wheezy,  incapable  of  exercise,  looking  older  than  their  years,  are  very  bad. 
They  that  are  fat,  florid,  and  plethoric,  firm-skinned,  and  with  good  muscular  power, 


244  OPERATIONS    ON    THE    HEAD   AND    NECK. 

— his  hal)its,  how  long  he  probably  has  before  him  if  no  operation  is 
j)erforme(l ;  whether  the  disfigurement  seriously  interferes  with  the 
following  of  an  active  life ;  whether  there  have  been  any  brain  symp- 
toms referable  to  the  growth  ;  the  condition  of  the  viscera;  any  lia- 
bility to  erj'sipelas;  finally,  each  case  being  considered  by  itself, 
certain  conditions  will  justify  operations  in  otherwise  doubtful  cases, 
as  when  a  rodent  ulcer,  having  destroj^ed  the  sight  of  one  eye,  is  creep- 
ing across  the  nose  and  threatening  the  opposite  one. 

ii.  The  Operation  Itself. — In  these  days  of  aseptic  surgery,  the 
combined  operation  by  knife  and  caustics,  or  cautery,  will  be  pre- 
ferred to  one  by  caustics  alone,  on  account  of  its  greater  precision,  and 
more  rapid  and  more  painless  healing,  from  the  absence  of  fetid 
sloughs,  and  the  diminished  liability  to  erysipelas,  etc.  The  follow- 
ing hints  may  be  found  useful  in  an  extensive  operation  for  rodent 
ulcer : 

(1.)  To  diminish  the  risks  of  erysipelas  in  these  patients  the  ulcer 
and  the  surrounding  parts  should  be  carefully  cleansed  and  kept  as 
aseptic  as  possible  by  means  of  precautions  similar  to  those  given  at 
p.  227. 

(2.)  Steps  of  the  operation  itself  and  the  application  of  caustics. — 
The  surgeon  first  makes  a  groove-like  incision*  around  the  whole,  or, 
in  a  very  extensive  case,  around  part  of  the  growth,  and  well  wide  of 
it,  and  arrests  the  bleeding  by  ligature,  leaving  on  Spencer  Wells's  for- 
ceps, or  by  sponge-pressure.  The  next  step — that  of  removing  the 
affected  soft  parts — is  often  difficult,  owing  to  their  jjroneness  to  break 
away,  and  thus  giving  no  firm  hold  to  forceps ;  a  sharp  spoon  is  often 
very  useful  here,  but  scraping  alone  is  not  to  be  trusted  to.  Having 
scraped  away  the  growth  down  to  tissues  apparently  healthy,  the  sur- 
geon scrutinizes  these  most  carefully,  picking  out  every  atom  of 
yellow-gray  granulation-like  material,  and  then  again  repeating  the 
scraping  with  careful  thoroughness.  Where  the  bones  themselves 
appear  eaten  into,  scraping  will  not  be  sufficient,  and  it  will  be  wiser 

clear-headed,  and  willing  to  work  like  younger  men,  are  not,  indeed,  very  good  sub- 
jects for  ofierations,  yet  they  are  scarcely  bad.  The  old  j)eople  that  are  thin  and  dry 
and  tough,  clear-voiced  and  bright-eyed,  with  good  stomachs  and  strong  wills,  muscu- 
lar and  active,  are  not  bad  ;  they  bear  all  but  the  largest  operations  very  well.  But 
very  bad  are  they  who,  looking  somewhat  like  these,  are  feeble  and  soft-skinned,  with 
little  pulses,  bad  appetites,  and  weak  digestive  power,  so  that  they  cannot,  in  an 
emergency,  be  well  nourished."  Sir  James  goes  on  to  speak  of  their  inability  to  bear 
loss  of  blood,  the  lazy  healing  of  large  wounds,  the  liability  of  their  stomachs  to  refuse 
food,  their  prolonged  convalescence,,  tlieir  getting  "all  but  well,"  and  the  need  of 
meeting  these  special  dangers  with  special  cares. 

*  A  jiairof  sharp,  blunt-pointed  scissors  may  be  found  useful  when  the  lids  Iiave  to 
be  cut  through. 


OPERATIVE  TREATMENT  OF  RODENT  ULCER.         245 

to  go  over  the  worm-eaten  surface  with  a  line  gonge  or  chisel*  In 
one  region  especially  these  must  be  used  with  the  utmost  caution — 
i.e.,  where  the  paper-like  bones  on  the  inner  Avail  of  the  orbit  are  in- 
volved ;  in  this  place,  if  the  surgeon  is  not  satisfied  with  the  limited 
use  of  the  gouge  or  chisel — which  is  alone  permissible  here— he  must 
be  content  with  finally  applying  Paquelin's  thermo-cautcry,  unless 
removal  of  the  eye,  at  the  same  time,  has  allowed  of  the  use  of  zinc 
chloride  paste.  In  other  places  this  most  valuable  caustic  may  be 
used  fearlessly,  as  long  as  precautions  are  taken  to  use  it  in  a  concen- 
trated form,  and  to  apply  it  as  firmly  and  as  thinly  as  possible,  so  that 
the  discharges  from  the  wound  shall  not  allow  it  to  liquefy  and  run 
either  towards  the  eye  or  nose  or  throat. 

(3.)  Advisability  of  preserving  the  eye  in  cases  where  the  conjunc- 
tiva is  involved.  As  a  rule,  in  these  cases,  consent  should  be  asked 
to  remove  the  eye  if  needful.  Cases  clearly  requiring  this  step  will 
be  those  where  (a)  the  eye  is  already  useless,  or  so  distinctly  deteri- 
orated that  it  cannot  improve;  (,^)  where  the  lids  have  shrunk  off 
away  from  it  and  left  it  irritable  and  painful  from  exposure  ;  (y) 
where  the  disease  cannot  otherwise  be  removed,  and  where  caustics 
cannot  otherwise  be  made  use  of. 

As  a  rule,  if  the  conjunctiva  is  much  involved,  the  necessar}-  re- 
moval of  this  will  cause  sloughing.  Occasionally,  this  only  threatens, 
and  then  passes  away.  Thus,  some  months  ago  a  patient  of  Drs.  T. 
and  J.  B.  Howell,  at  Wandsworth,  came  under  my  care  for  extensive 
rodent  ulcer.  Both  lids  of  the  right  eye,  the  conjunctiva  largely,  the 
inner  part  of  the  orbit,  root  and  right  side  of  the  nose,  and  upper  part 
of  right  cheek  were  involved.  Operation  had  been  advised  ten 
years  before,  the  disease  being  of  much  longer  duration  still.  After 
removal  of  the  soft  parts  involved  by  the  growth,  it  was  found  that 
the  lachrymal  and  ethmoid  had  been  especially  involved,  being  very 
vascular  and  worm-eaten.  Repeated  applications  of  the  sharp  spoon 
and  a  small  gouge  were  made  use  of,  and  finally  Paquelin's  thermo- 
cautery was  applied.  The  inner  half  of  the  conjunctiva  was  involved, 
and  removed  freely,  the  internal  rectus  being  largely  exposed.  The 
cornea  became  cloudy  and  discolored,  and  though  on  the  third  day 
the  pupil  was  visible  and  the  patient  could  distinguish  between  the 
medical  men  at  his  bedside,  the  cornea  ultimately  sloughed,  and  I 
removed  the  eyeball  a  few  weeks  later.f 

*  Mr.  Moore  {loc.  supra  cit.,  p.  51)  speaks  decisively  On  this  point:  "Thel>i)ne  itself 
must  he  taken  away  to  a  depth  exceeding  tliat  wliich  lias  yielded  to  the  dispose.  Re- 
currence is  otherwise  inevitable."  Mr.  Moore  seems  to  iiave  used  cutting  lionc-piiers 
for  tills  ]>Mrpose. 

t  It  wonld  certainly  have  i;een  wiser  to  have  removed  tlie  eye  at  tlie  first  operation, 
a  step  wiilcli  would  liave  facilitated  tlie  use  of  zinc  chloride  paste.     Th<>  i)atient,  liow- 


246  OPERATIONS    ON    THE    HEAD    AND    NECK. 

iii.  The  After-Treatraent. — (1)  Tlie  chief  object  here  is  to  keep 
the  wound  scrupulously  sweet.  I  prefer  for  this  gently  packing  the 
wound  with  iodoform  gauze,  or,  in  cases  where  erysipelas  may  be  ex- 
pected, dusting  with  iodoform,  and  dressing  with  boracic  acid  lint 
soaked  in  a  saturated  solution  of  the  acid,  and  changed  at  regular  in- 
tervals. Sufficient  morphia  should  be  given  for  the  first  day  or  two, 
and  the  bowels  kept  regularly  open.  If  zinc  chloride  paste  has  been 
used,  attention  must  be  paid,  as  already  advised,  that  it  does  not  melt 
and  run  into  parts  like  the  eye,  nose,  or  mouth,  and  for  this  pur- 
pose the  position  of  the  patient's  head  must  be  looked  to.  (2)  If  it 
has  been  found  needful  to  attack  vigorously  the  bones  of  the  skull,  or 
even  to  apply  some  of  the  caustic  to  diseased  dura  mater,  and  if  dur- 
ing the  first  ten  days  of  the  disease  fits  make  their  appearance,  it  does 
not  necessarily  follow  that  cerebral  inflammation  is  setting  in.  Ac- 
cording to  Mr.  Mcmre*  the  fits  may  be  slight  and  the  unconsciousness  of 
brief  duration,  or  the  fits  even  severe  and  attended  with  coma,  but,  as 
a  rule,  they  are  recovered  from.  (3)  Secondary  haemorrhage.  This 
is  rare  after  the  use  of  zinc  chloride,  which  forms  a  deep,  black  slough, 
and  also  seems  to  me  to  prevent  the  risk  of  pyjemia.  But  if  the 
cautery  only  has  been  used,  the  amount  of  foetor  is  much  greater,  and 
in  parts  so  vascular  that  secondary  hsemorrhage  may  easily  occur,  if 
the  wound  is  foul.  (4)  Recurrence.  The  patient  must  always  be 
most  carefully  watched,  and,  in  the  case  of  extensive  and  deep  disease, 
any  suspicious  granulations  that  appear  must  be  attacked  at  once. 
(5)  When  after  a  severe  operation  a  plastic  operation  cannot  be  per- 
formed, very  much  may  be  done  by  a  well-made  vulcanite  mask.f 

REMOVAL  OF  PAROTID  GROWTHS. 

The  question  of  operation  arises  here  under  three  somewhat  differ- 
ent conditions — viz.  : 

(i.)  In  the  case  of  the  ordinary  parotid  tumor. 

(ii.)  In  that  of  a  sarcoma  of  the  parotid,  which  has  often  started  in 
the  growth  just  mentioned. 

(iii.)  In  carcinoma  of  the  parotid. 

(i.)  Removal  of  an  Ordinary  Parotid  Tumor.— These  well- 
known  growths,  containing  a  mixture  usually  of  fibro  cartilaginous, 
myxomatous,  and  imperfect  glandular  tissue,  require  no  especial  allu- 
sion here,  beyond  the  need  of — (1)  Exposing  them  sufficiently,  (2) 
Paying  strict  attention  to  the  facial  nerve,  and  (3)  Removing  the  cap- 
ever,  had  so  much  difficulty  in  making  up  his  mind  to  be  operated  on,  tiiat  it  was 
thought  best  to  attempt  to  do  without  the  additional  mutilation  if  possible. 

*  Loc.  supra  cit ,  p.  54. 

f  As  is  shown  in  Figs.  6  and  7  in  Mr.  Moore's  book,  loc.  supra  cit. 


RExMOVAL    OF    PAROTID    TUMORS.  247 

sule  itself,  after  the  growth  has  been  shelled  out,  in  any  cases  of  doubt 
— viz.,  soft  consistency,  rapid  growth.* 

(ii.)  Operation  in  Sarcoma  of  the  Parotid.— This  most  fre- 
quently originates  in  one  of  the  growths  just  mentioned.  This  and 
the  next  group  may,  as  far  as  operative  steps  go,  be  considered 
together,  it  being  remembered  that  tliere  is  this  wide  difference 
between  them,  that  carcinomata  are  here  far  more  malignant,  as  a 
rule,  than  sarcomata  .f 

(iii.)  Operation  in  Carcinoma  of  the  Parotid.— The  question 
of  the  avdvisability  of  interfering  at  all  with  really  malignant  growths 
of  the  parotid,  especially  carcinomata,  has  been  much  disputed,  but 
as  each  case  must  be  decided  by  itself,  and  as  no  hard-and-fast  line 
can  be  laid  down  here,  some  practical  points  which  will  be  found 
useful  may  be  mentioned.  On  the  one  hand,  attention  must  be 
stronglv  drawn  to  the  fact  that  reports  of  operations  here  are  often 
brief,  and  that  too  often  they  are  published  as  soon  as  the  patient 
leaves  his  surgeon,  and  thus  two-thirds  of  their  value  are  lost ;  on  the 
other  hand,  I  may  perhajis  venture  to  advise  my  younger  readers  that 
a  malignant  tumor  in  this  region  is  one  in  which,  above  most  others,  he 
must  not  allow  a  wish  to  relieve  a  patient  to  overcome  a  decision 
arrived  at  after  careful  examination,  for  there  is  scarcely  any  other 
part  of  the  body  in  which  a  malignant  growth  more  quickly  obtains 
a  firm  hold  on  the  surrounding  structures — a  fact  which  has  even  a 
more  grave  bearing  on  the  operation  than  the  importance  of  these 
structures  themselves. 

Practical  Points  in  the  Removal  of  Parotid  Tumors. 

Characters  of  the  Tumor. — Amongst  the  most  notable  of  these  are — 
(1)  Mobility — viz.,  how  far  it  can  or  cannot  be  lifted  up  by  the  fingers 
from  the  subjacent  parts.  (2)  Rapidity  of  growth.  (3)  Density — thus 
a  great  hardness  or  evident  softness  will  be,  alike,  unfavorable,  the 


*  In  an  article  ((rui/'s  Ifosp.  Renoi'ts,  vo].  xxvi.)  "On  tlie  EncIiondron)ata  <il'  tlie 
Salivary  Glands,"  I  ventured  to  say,  with  regard  to  the  removal  of  these  growths,  "  If 
the  wuinid  be  made  too  small  in  the  first  case  for  fear  of  a  scar,  the  edges  will  only  be- 
brnised  and  primary  union  be  prevented.  It  is  not  uncommon  for  branches  of  the 
facial  nerve  to  be  in  relation  with  the  capsule  of  the  tumor,  and  if  tliis  has  been  much 
handled,  or  treated  by  counter-irritation,  they  may  very  likely  be  firmly  adherent. 
In  either  case  injury  to  the  nerve  may  be  best  avoided  by  slitiiug  up  the  capsule  and 
shelling  out  the  enchondroma  first.  The  capsule  should  then  be  examined  to  see  if 
anv  nerve  branches  are  adherent  to  it;  after  these  have  been  separated,  the  capsule 
itself  sho\ild  be  removed.  This  shoidd  always  be  done  to  prevent  any  recurrence,  as 
the  peripheral  part  of  these  enchondromata  is  often  adherent  to  the  capsule  itself. 

t  Thus  Mr.  Butlin  (Oper.  Surg,  of  Mnlig.  Dis.,  p.  117)  speaks  of  carcinoma  here  as  a 
very  dangerous  and  fatal  disease,  but  of  sarcoma  as  appearing,  whether  iu  the  pure  or 
mixed  forms,  to  be  a  far  more  benign  disea>;e  than  sarcoma  of  most  of  the  other  parts- 
of  the  bod  v. 


248  OPERATIONS   ON    THE    HEAD    AND    NECK 

latter  from  the  fact  that  such  soft  growths  will  break  down  during 
,  attempts  at  removal,  and  leave  parts  behind.  (4)  Pressure  symptoms. 
Of  these,  dyspnoea,  dysphagia,  presence  of  outlying  masses  in  the 
fauces,  and  facial  paralysis*  are  of  evil  omen.  (5)  Condition  of  the 
overlying  skin.f 

Points  in  the  Operation  Itself. — To  begin  witli,  the  growth  must  be 
sufficiently  exposed  by  adequate  incisions.  Probably  none  will  be 
more  generally  suitable  than  a  h- -shaped  incision,  the  longitudinal 
portion  lying  over  the  large  vessels,  and  the  transverse  one  exposing 
the  facial  part  of  the  growth. 

If  the  skin  is  adherent  at  any  spot  this  should  be  removed  at  the 
same  time.  The  growth  being  sufficiently  exposed,  the  extirpation  of 
it  had  best  be  begun  in  front  and  above,:{:  the  posterior  part  being  left 
to  the  last,  as  here  lies  the  most  important  relations,  and  as  these  can 
be  most  readily  dealt  with  when  the  growth  has  been  freed  elsewhere. 
During  the  operation  a  blunt  dissector  should  be  used  as  much  as 
possible,  aided  by  touches  of  a  blunt-pointed  bistoury,  and  l)y  drag- 
ging the  growth  in  different  directions.  Every  vessel,  as  soon  as  cut, 
should  be  secured  with  Spencer  Wells's  forceps,  and  the  free  oozing 
from  the  vascular  skin  and  other  parts  arrested  by  sponge  pressure 
while  the  surgeon  is  engaged  with  some  other  part  of  the  growth. 

M.  Malgaigne  §  advised  that  when  the  surgeon  was  working  poste- 
riorly and  deeply  he  should  have  the  mouth  widely  opened,  as  this 
movement,  by  removing  the  condyle  from  the  meatus,  enlarged  the 
space  in  which  the  instruments  Avere  working. 

In  addition  to  the  free  oozing,  and  the  presence  of  important  vessels, 
other  difficulties  which  may  present  themselves  are  the  breaking  down 
of  a  soft'growth,  thus  baffling  attempts  at  complete  extirpation,  and 
the  strong  processes  of  fibrous  tissue  which,  passing  normally  from 
the  parotid  to  some  important  adjacent  structures— viz.,  the  digastric, 

*  Prof.  Billroth,  quoted  by  Mr.  Batlin  {he.  supra  cit.,  p.  118),  considers  that  the 
occurrence  of  facial  paralvsis  from  the  pressure  of  a  parotid  tumor  is  to  be  regarded  as 
a  sign  iliat  it  is  probably  a  carcinoma,  for  the  sarcomata  and  other  tumors  rarely  pro- 
duce pandysis  by  pressure,  although  paralysis  frequently  follows  the  operation  for 
their  removal. 

f  Tiie  more  adherent,  discolored — viz.,  reddish  purple — are  the  integuments,  the 
more  imfavorable  is  the  prognosis. 

X  M.  Berard  (Maladies  de  la  Gland  parotide,  p.  240)  advises  that  after  the  growth 
has  been  freed  in  front,  it  should  be  next  attacked  from  below  upwards,  and  not  from 
above  downwards,  for  these  reasons — (1)  The  blood  flows  away  from  the  womid,  and 
not  over  the  instruments  of  the  surgeon  ;  ( 2)  the  same  vessels  do  not  have  to  be  tied 
more  tiian  once;  (3)  if  any  large  vessel  has  to  be  cut,  it  is  secured  early,  thus  dimin- 
ishing the  amount  of  hiemorrhage 

^    Operative  Surgery  (translated  by  Dr.  Brittan),  ]).  349. 


EEMOVAL    OF    PAROTID    TUMORS.  249 

the  internal  pterygoid,  and  the  carotid  sheath — are  now  liable  to  be 
either  increased  in  density  or  softened  by  extension  of  the  growth. 

Two  points  will  require  especial  attention  here — viz.,  the  amount  of 
facial  paralysis  which  may  be  expected,*  and  the  question  of  ha?m- 
orrhage. 

Facial  Paralysis. — While  in  the  case  of  a  smaller  growth,  if  the 
nerve  has  only  been  bruised,  or,  when  divided,  if  the  ends  have  been 
placed  in  contiguity,  union  may  take  place,  and  the  paralysis  gradu- 
ally disappear,!  in  the  case  of  really  malignant  growths  the  question 
of  future  deformity  must  be  set  aside,  and  the  nerve  divided  as  soon 
as  seen. 

Best  Modes  of  Meeting  Hsemorrhage.— The  chief  vessels 
which  will  be  met  with  are,  the  superficial  temporal,  transverse  facial, 
occipital,  posterior  auricular,  the  internal  maxillary,  and  external 
carotid.  The  external  jugular  vein,  large  communicating  branches 
between  it  and  the  internal  jugular  are  sure  to  be  cut,  while  the 
internal  jugular  vein  is  almost  certain  to  be  seen  in  the  bottom  of  the 
wound. 

It  must  be  remembered  that  not  only  will  all  the  above  vessels  be 
liable  to  be  much  enlarged,  but  numerous  other  unnamed  anastomoses 
will  be  present. 

The  common  carotid  has  several  times  been  tied  prior  to  this  opera- 
tion. With  all  due  deference  to  those  who  have  adopted  this  practice, 
I  would  advise  that  this  step  should  be  dispensed  Avith  if  possible, 
and  for  these  reasons — (1)  It  introduces  certain  grave  additional  risks 
of  its  own.  (2)  It  takes  up  time  which  will  be  wanted  in  tlie  opera- 
tion itself,  especially  if  the  projection  downwards  of  the  growth  into 
the  neck  overlaps  and  conceals  the  position  of  the  vessel.  (3)  It  is 
by  no  means  a  certain  preventive  of  hsemorrhage  here,  any  more  than 
ligature  of  both  Unguals  can  always  be  relied  on  to  prevent  htemor- 
rhage  during  extirpation  of  the  tongue.  (4)  This  step,  recommended 
by  many  of  the  older  surgeons,  is  not  so  needed  now  in  these  days  of 
ansesthetics,  with  an  almost  unlimited  variety  of  forceps  and  ligatures 
at  hand.  (5)  Finally,  it  would  appear  better,  because  simpler  and 
equally  efhcient,  to  meet  the  haemorrhage  from  the  large  vessels  before 
they  are  cut,  by  taking  them  up  with  two  pairs  of  Spencer  Wells's 
forceps,  dividing  the  vessel  between  these,  and  tying  or  twisting  both 
ends. 

*  If  the  surgeon,  especially  in  less  serious  cases,  when  making  any  deep  incision 
that  is  needful,  can  manage  not  to  go  above  the  level  of  a  line  drawn  iiorizontally  | 
inch  below  the  lobule  of  the  ear,  he  will  avoid  any  serious  interference  wiili  the  trunk 
of  the  facial  nerve,  and  thus  escape  the  risk  of  permanent  paralysis. 

f  This  gradual  improvement  in  facial  paralysis  is  alluded  to,  with  a  c;ise  in  point, 
in  my  article, /oc.  mpra  cit.  Mr.  B:Ulin  [loc.  supra  cit ,  p.  120)  suggests  a  trial  of 
nerve-suture  iiere. 


250  OPERATIONS    ON    THE    HEAD    AND    NECK. 

In  dealing  with  any  large  veins  the  risk  of  the  entrance  of  air  should 
be  prevented  by  making  finger-pressure  on  the  cardiac  side,  or  by 
securing  them  with  double  ligatures  before  they  are  cut. 

If  ligature  of  the  common  carotid  is  to  l)e  made  use  of  here,  it  should, 
in  my  opinion,  be  reserved  for  those  cases  in  which  the  surgeon  decides 
to  attack  a  very  soft  and  vascular  growth,  as  here  tlie  vessels  may  be 
very  numerous  and  difficult  to  isolate,  and  ligatures  may  be  found  not 
to  hold.  In  such  a  case,  instead  of  tying  the  comnjon  carotid  and  thus 
exposing  the  patient  to  the  risks  of  brain  mischief,  it  would  be  better 
to  pass  a  loop  of  chromic  catgut  ligature  around  the  vessel,  loosely 
tied,  and  to  ask  an  assistant  to  keep  up  tension  on  this  whenever  much 
bleeding  takes  place.  This  method  seems  to  have  been  first  made  use 
of  by  M.  Roux,  and  much  more  recently  in  this  country  by  Mr.  Riv- 
ington  *  and  Mr.  Treves.f 

If  the  wound  has  become  foul — and  sometimes  in  these  operations 
near  the  mouth  and  nose  it  is  impossible  to  keep  the  bandages  from 
shifting — the  surgeon  must  always  be  prepared  for  the  accident  of  sec- 
ondary ha?morrhage.  And  on  account  of  the  same  risk  the  actual 
cautery  should  never  be  used  at  the  bottom  of  a  very  deep  wound  near 
to  any  suspicious  tissues,  if  it  can  be  possibly  avoided.  If  some  caustic 
is  required,  zinc-chloride  paste,  used  with  the  precautions  given  at  p. 
245,  would,  I  tliink,  be  preferable  from  the  absence  of  foetor  with  which 
it  works,  and  the  drv  black  scabs  it  forms. 


CHAPTER  V. 


EXCISION  OF  THE  EYEBALL  AND  CLEARING 
OUT  OF  THE  ORBIT. 

EXCISION  OF  EYEBALL.: 
Indications. 

i.  New  growths — e  g.,  glioma  of  the  retina,  melanotic  sarcoma  of  the 
uveal  tract. 

ii.  In  the  following  cases  of  injury  and  its  results : 
(a)  The  eyeball  ruptured  and  collapsed  after  a  blow. 
(h)  A  large  jagged  foreign  body  in  the  eye — e.g.,  a  bit  of  metal, 
not  removable  without  inevitable  disorganization. 

*  Med.-Chir.  Trans,  vol.  Ixix.  p.  72. 
t  Lancet,  January  21,  1888. 

J  As  the  general  surgeon  may  be  called  upon  to  perform  this  operation  at  anytime, 
and  as  it  should  always  be  practiced  on  the  dead  body,  it  is  included  here. 


EXCISIOX    OF    EYEBALL.  251 

(c)  If  (Nettleship's  Diseases  of  the  Eye,  p.- 142)  the  wound,  lying 

wholly  or  partly  in  the  dangerous  region,*  be  so  large  and 
so  complicated  with  injury  to  deeper  parts  that  no  hope  of 
useful  sight  remains. 

(d)  If,  though  the  wound  be  small,  it  lie  in  the  dangerous  region, 

and  have  already  set  up  irido-c3'clitis. 

(e)  Where  a  small  foreign  body — e.g.,  a  shot  glancing  in  cover- 

shooting,  not  removable  by  an  electro-magnet,  gradually  sets 
up  inflammation  and  shrinking  of  the  eye. 
(/)  When  there  is  a  wound  in  the  dangerous  region  complicated 

with  traumatic  cataract. 
(g)  When  traumatic  cataract  has  been  set  up  by  a  wound  which 
is  wholly  corneal,  and  therefore  out  of  the  dangerous  area, 
and  yet  severe  iritis  and  pan-ophthalmitis  come  on  in  spite 
of  treatment, 
iii.  As  part  of  an  operation  for  rodent  ulcer  which  has  extensively 
involved  the  conjunctiva  (p.  245). 

iv.  As  part  of  an  operation  for  removal  of  orbital  tumors— e.^f.,  a 
glioma  or  sarcoma  which  has  ruptured  the  sclerotic,  rodent  ulcer, 
scirrhous,  sarcomatous,  congenital,  bony  growths,  etc.f 

Operation. — The  chief  object  is  to  remove  the  globe  alone,  when- 
ever this  is  possible,  leaving  the  muscles  to  coalesce  and  form  a  stump 
on  which  the  artificial  eye  may  be  supported  and  be  movable.  As 
much  conjunctiva  as  possible  should  be  left. 

The  surgeon,  standing  in  front,  having  inserted  a  spring-speculum 
between  the  lids,  snips  with  blunt-pointed  scissors  through  the  ocular 
conjunctiva  close  to  the  cornea  and  all  round  it,  using  toothed  forceps 
to  lift  the  conjunctiva,  and  leaving  enough  at  one  side  to  hold  on  by 
the  forceps  during  the  next  step.  This  is  to  open  freely  Tenon's  cap- 
sule, and  catching  up  each  rectus  tendon  (beginning  usually  with  the 
external  rectus),  with  a  strabismus  hook  to  divide  them  close  to  the 
sclerotic,  leaving  the  cut  end  of  the  external  rectus  long,  in  order  to 
draw  the  eyeball  forcil»ly  inwards.  The  superior  and  inferior  rectus 
are  then  cut,  and  the  speculum  pressed  back  into  the  cavity  of  the 
orbit  so  as  to  make  the  eye-ball  start  forwards.  The  scissors,  blunt- 
pointed  and  slightly  curved,  are  now  passed  back  to  feel  for  the  optic 
nerve,  which  may  be  known  by  its  toughness  and  thickness,  and  which 
is  now  severed  with  one  clean  cut.  The  eye-ball  being  drawn  forwards 
with  a  finger,  the  oblique  muscles  and  any  remaining  soft  parts  are  to 
be  cut  close  to  the  globe.  Sponge  pressure  is  then  to  be  applied  firmly 
for  a  few  minutes,  and  for  the  first  ten  hours  aseptic  sponges  and  a 

*  A  zone  nearly  J  inch  wide  surrounding  the  cornea. 

t  For  an  excellent  account  of  these  the  reader  is  referred  to  Mr.  Lawson's  article, 
Diet,  of  Surg.,  vol.  ii.  p.  117  et  seq. 


252  OPERATIONS    ON    THE    HEAD    AND    NECK. 

bandage  should  be  worn  to  prevent  temporary  but  troublesome 
haemorrhage. 

In  the  case  of  a  new  growth — e.g.,  glioma — the  optic  nerve  must  be 
divided  as  far  back  as  possible.  The  scissors,  slightly  curved  and  long 
enough  to  reach  to  the  back  of  the  orbit,  are  introduced  on  the  inner 
side,  and  the  nerve  either  cut  as  far  back  as  is  possible  before  the  globe 
is  removed,  or,  after  this  is  done,  the  nerve  is  dissected  out  and  a  fresh 
slice  taken. 

Where  there  is  any  suspicion  of  growth,  as  in  a  glioma  of  the  optic 
nerve,  being  left  behind,  zinc-chloride  paste  should  be  api^lied,  as 
at  p.  245. 

Owing  to  the  early  stage  at  which  dissemination  of  intra-ocular  sar- 
comata takes  place,  and  to  the  tendency  of  gliomata  to  creep  back- 
wards along  the  optic  nerve  towards  the  interior  of  the  cranium,  the 
prognosis  very  largely  dei)ends  upon  the  earlinesi;  of  the  extirpation. 
On  this  account  it  should  be  remembered  that  the  earliest  symptoms  of 
these  growths,  viz.,  impairment  of  sight  from  partial  detachment  of 
the  retina  by  the  pressure  of  the  growth  behind  it — should  be  most 
carefully  tested  in  suspicious  cases,  this  impairment  of  sight  being  not 
usually  noticed  by  the  patient,  save  accidentally  on  closing  the  sound 
eye,  unless  the  growth  originates  near  the  yellow  spot.  If  later  evi- 
dence is  waited  for,  such  as  evidence  of  tension  and  pain,  dissemina- 
tion or  recurrence  is  most  probable,  while  the  growth  will  very  likely 
have  perforated  the  eye,  and  the  severer  operation  of  clearing  out  the 
orbit  will  be  required. 

The  following  questions  Avill  very  likely  arise:  If  there  is  evidence 
of  general  dissemination  of  the  disease,  is  it  expedient  to  remove  the 
eye,  or,  if  this  be  insufficient,  to  clear  out  the  orbit  as  well?  In  most 
cases  the  answer  will  be  in  the  affirmative,  in  order  to  save  the  patient 
pain,  and  the  misery  of  the  protruding  and  ulcerating  mass. 

If  the  disease  has  recurred,  is  it  any  vise  to  again  attack  it?  Each 
question  here  must  be  decided  by  itself.  The  answer  will  mainly 
depend  on  the  amount  and  depth  of  the  recurrence,  and  on  the  com- 
pleteness of  the  first  operation.  Thus,  if  the  eye  only  was  removed  at 
first,  it  may  be  wise  to  clear  out  the  orbit  thoroughly. 

In  a  few  most  distressing  cases  in  children  it  is  well  known  that  both 
eyes  are  attacked.  The  question  of  operating  on  the  second  eye  must 
here  be  faced.  Opinions  here  differ  somewhat.  Mr.  Butlin*  thinks 
that  it  is  better  not  to  operate  in  such  cases,  "  although  the  operation 
may  be  regarded  as  justifiable  in  order  to  prevent  the  occurrence  of 
fungous  protrusion  and  the  pain  and  misery  which  are  associated  with 
it."     Mr.   Lawson,t  on  the  other  hand,  holds  that  if  both  eyes  are 

*  Loc.  supra  cit.,  p.  S8. 

t  Diet,  of  Surg.,  vol.  ii.  p.  124. 


CLEARING    OUT    THE    ORBIT.      "  253 

affected,  both  should  be  excised,  providing  that  the  sight  has  ah-eady 
been  destroyed.  He  has,  on  many  occasions,  removed  the  second  eye 
to  procure  temporary  relief  from  the  excessive  pain  induced  by  the 
over-distended  globe,  and  when  there  has  not  been  the  slightest  pros- 
pect of  arresting  the  disease.  In  each  case  the  operation  gave  imme 
diate  and  perfect  relief. 

OPERATION  OF  CLEARING  OUT  THE  CONTENTS  OP 

THE  ORBIT. 

Indications — This  operation  will  be  briefly  given  here,  as  it  is 
required,  though  not  frequently,  in  growths  which,  originating  in  the 
eye,  extend  to,  or  recur,  in  the  orbit ;  in  the  case  of  sarcomatous  (peri- 
osteal) or  scirrhous  tumors  of  the  orbit;  and  in  rodent  ulcer,  in  which 
an  operation  has  been  long  deferred  by  the  patient,  and  the  growth 
has  consequently  attacked  the  conjunctiva  and  eye,  and  involved  the 
bones  of  the  orbit  as  well. 

Operation. — In  most  cases  it  will  be  well  to  enucleate  the  eye  first, 
and  then  to  excise  the  growth,  partly  shelling  it  with  a  periosteal 
elevator  from  the  bones  themselves,  partly  dividing  the  structures 
behind  Avith  stout,  short,  curved  scissors. 

Mr.  Butlin,*  quoting  from  Arlt,  advises  that,  to  begin  with,  the  outer 
commissure  of  the  lids  be  split,  the  lids  raised  off  the  growth  by 
dividing  the  uniting  conjunctiva,  and  then  turned  back  and  fastened 
out  of  the  Avay.  "If  the  periosteum  is  adherent  to  the  tumor,  and  it 
is  considered  expedient  to  remove  it,  it  must  be  incised  at  the  margin 
of  the  orbit,  where  it  adheres  firmly  to  the  bone,  with  a  sharp  scalpel, 
after  which  it  is  raised  up  from  the  bone  in  the  same  way  as  the  con- 
tents of  the  orbit  were  separated,  and  removed  either  in  whole  or 
part." 

In  working  in  the  inner  side  the  surgeon  must  remember  the  natural 
thinness  of  the  bones  here  when  in  a  healthy  state;  both  here  and 
elsewhere,  as  in  the  roof,  the  growth  has  very  likely  exerted  a  thin- 
ning effect. 

If  any  suspicious  points  remain,  the  surgeon  goes  over  these  again 
with  a  sharp  scoop,  gouging  out  any  suspicious  patches  in  the  bone, 
and  finally  applying  the  thermo-cautery,  or  caustics,  or  both.  Mr. 
Lawson  t  gives  the  following  method  of  applying  the  zinc-chloride 
paste,  so  as  to  avoid  the  sloughing  of  the  eye-lids  from  the  caustic 
extending  to  them  : 

After  the  eye  and  tumor  have  been  excised,  pressure  is  to  be  made 
in  the  orbit  until  all  bleeding  has  ceased.     The  mouth  of  the  con- 

*  Loc.  supra  cit.,  p.  80. 

t  Diet,  of  Surg.,  vol.  ii.  p.  118. 


254  OPERATIONS    ON    THE    HEAD    AND    NECK. 

junctival  bag,  from  which  the  e^^e  has  been  enucleated,  is  now  to  be 
held  o])en  with  two  pairs  of  forceps,  whilst  the  zinc-chloride  paste, 
spread  on  lint,  is  plastered  round  the  sides  of  the  orbit.  A  small  piece 
of  cotton-wool  is  next  introduced  to  keep  the  strips  of  lint  in  situ,  and 
the  mouth  of  the  conjunctival  bag  is  closed  over  the  whole  by  a  single 
continued  suture.  A  layer  of  oiled  lint  is  then  placed  over  the  con- 
junctiva, and  upon  this  the  lids  are  closed  and  kept  in  position  with 
a  compress  of  lint  and  a  roller. 

On  the  day  following  the  operation  the  bandage  may  be  removed, 
or  if  there  is  much  tension  of  the  lids  from  the  stuffing  within  the 
orbit,  some  of  the  cotton-wool  may  be  gently  drawn  out.  The  remain- 
der should  be  taken  away  on  the  second  day,  and  a  little  fresh  ab- 
sorbent wool  laid  loosely  within  the  orbit  to  absorb  the  discharges,  as 
soon  as  suppuration  commences. 

This  should  be  repeated  daily,  but  the  pieces  of  lint  on  which  the 
zinc-chloride  has  been  applied  should  not  be  removed  until  suppura- 
tion has  quite  loosened  them.  After  about  ten  or  twelve  days  the 
sloughs  will  separate  from  the  orbit,  and  if  any  suspicious  granulations 
spring  up  they  should  be  touched  with  the  solid  zinc-chloride  or  with 
the  potassa-cum-calce.* 


CHAPTER  VI. 

OPERATIONS  ON  THE  NOSE. 

RHINOPLASTY  OR  PLASTIC  OPERATIONS  FOR  THE 
REPAIR  OF  THE  NOSE— ROUGE'S  OPERATION- 
REMOVAL  OF  NASAL  POLYPI. 

PLASTIC  OPERATIONS  FOR  THE  REPAIR  OF  THE 
NOSE  (Figs.  50-57). 

These  operations  may  be  divided  into  those  for  complete  and  par- 
tial restoration. 

Indications. — When  the  patient  is  healthy  and  fairly  young,  when 
the  cause  of  the  destruction — viz.,  lupus,  gunshot  injury,  syphilitic 
ulceration — new  growth  necessitating  removal  is  not  only  checked  but 
soundly  healed.f 

*  Mr.  Lawson  has  three  times  seen  epileptic  convulsions  follow  within  thirty-six 
hours  after  the  operation,  but  they  ceased  after  the  removal  of  the  zinc-chloride,  the 
patient  in  each  case  making  a  good  recovery  (p.  246).  If  convulsions  should  occur, 
Mr.  Lawson  advises  removing  the  zinc-chloride  and  syringing  out  the  cavity  with 
dilute  acetic  acid  (,^j — 3J). 

f  In  Sir  W.  MacCormac's  case,  quoted  below,  the  tip  and  al»e  of  the  nose  had 
sloughed  in  infancy  after  the  injection  of  a  large  nsevus  with  the  liquor  ferri  perni- 
tratis. 


EEPAIR    OF    NOSE. 


255 


Thus,  after  lupus  has  been  cured  by  scraping,  and  still  more  in  the 
case  of  syphilitic  ulceration,  it  will  be  well  to  wait  six  months  at  least 
after  the  disappearance  of  the  disease. 

A.  Operations  for  Complete  Restoration.— The  following 

will  be  found  the  most  useful : 

(1.)  Verneuil's,  by  Super-imposed  or  Double  Flaps  from 
Cheeks  and  Forehead  (Figs.  50,  51). 

(2.)  Syme's,  from  the  Cheeks  (Figs.  52,  53). 

(3.)  The  Indian  or  Frontal  (Fig.  54). 

(4.)  The  Italian  or  Tagliacotian. 

Before  deciding  which  operation  lie  will  make  use  of  in  restoring 
the  nose,  the  surgeon  Avill  investigate  the  following  points :  How  far 
is  the  bony  framework  of  the  nose  destroyed?  If  the  cartilages,  sep- 
tum, vomer,  ethmoid,  and  nasal  bones  are  much  removed,  however 
well  made  the  frontal  flap,  and  however  skilfully  it  is  adjusted,  it  will 


Fig.  50, 


Fig.  51. 


Verneuil's  incisimis  in  i  hiiifiplasty  for 
sunken  nose.    (Stimson.) 


Verneuil's  double  flaps  in  situ. 

The  frontal  flap  is  also  shown  with 

its  raw  surface.    (Stimson.) 


tend,  after  looking  extremely  w^ell  at  first,  to  sink  down  to  the  level  of 
the  cheeks.  Verneuil's  operation  meets  this  partially  by  its  double 
layers  or  flaps.  If  he  proposes  to  take  flaps  from  the  cheeks,  the  sur- 
geon must  inquire  how  far  these  are  plentiful,  and  free  from  old  scars. 
So,  too,  if  the  forehead  is  to  furnish  the  flaps,  how  far  is  it  a  capacious 
one  and  free  from  hairs  ? 

The  respective  advantages  of,  and  the  indications  for,  the  above 
operations  will  be  given  in  the  description  of  each  method. 

(1.)  VerneuiVs  Operation  (Figs.  50  and  51). — This  operation,  sug- 
gested to  M.  Verneuil  by  M.  Oilier,  was  employed  successfully  by  him 
in  order  to  secure  permanent  elevation  of  a  sunken  nose,  by  super- 


206  OPERATIONS    ON    THE    HEAD    AND    NECK. 

imposing  two  flaps  and  thereby  doubling  the  thickness.  The  patient 
had  discharged  a  pistol  into  his  mouth,  causing  the  destruction  of  a 
portion  of  the  hard  palate  and  septum,  the  nasal  bones,  part  of  the 
nasal  processes  of  the  superior  maxillary,  the  spine  of  the  frontal,  and 
the  anterior  wall  of  the  frontal  sinuses.  The  ahe  and  tip  were  unin- 
jured, but  much  flattened;  above  them  was  a  broad,  deep  groove,  ex- 
tending to  the  middle  third  of  the  forehead.  The  two  principal 
indications  were  to  bring  the  lateral  portions  nearer  the  median  line 
and  to  rebuild  the  bridge  of  the  nose.  The  latter  could  be  perma- 
nently accomplished  only  by  filling  in  the  great  cavity  which  would 
be  left  by  raising  the  sunken  parts. 

Verneuil  made  an  incision  along  the  median  line  of  the  depression 
and  a  transverse  one  at  each  end  of  the  first,  and  dissected  up  the  two 
lateral  flaps  thus  marked  out.  He  then  raised  an  oblong  flap  from 
the  middle  of  the  forehead,  leaving  it  adherent  l>etween  the  eyebrows, 
and  turned  it  directly  dow^nwards  so  that  its  raw  surface  was  directed 
outwards,  its  skin  surface*  looking  towards  the  nasal  fossa?.  The  two 
lateral  flaps  were  then  placed  upon  it  and  united  in  the  median  line. 
The  raw  surfaces  united  with  each  other,  and  the  result  was  a  nose 
elevated  i  inch  above  the  adjoining  surface.  The  wound  in  the  fore- 
head was  partly  closed  by  a  hare-lip  ])in  and  sutures,  and  later  on 
healed  by  skin-grafting.  The  pedicle  of  the  frontal  flap  will  require  ' 
dividing  and  trimming  subsequently. f  In  addition  to  the  advantage 
which  this  operation  possesses  of  rendering  a  sunken  nose  prominent, 
it  produces  ultimately,  from  my  experience  of  the  case  mentioned 
below,  but  little  scarring,  the  lateral  incision-scars  fading  away  gradu- 
ally into  the  naso-labial  sulci,  and  the  folds  beneath  the  eye. 

(2.)  Syme's,  from  the  Cheeks  (Figs.  52,  53). — This  method  is 
described  by  its  inventor  in  his  Observations  in  Clinical  Surgery,  p.  56. 
Besides  doing  away  with  a  frontal  scar,  this  method  enables  a  nose 
thus  constructed  to  have  its  sensations  in  correspondence  with  the 
part  from  which  it  was  derived. 

The  following  drawings.  Figs.  52,  53,  show  the  shape  of  the  flaps, 
and  the  manner  of  their  adjustment. 

New  flaps  of  the  shape  given  in  Fig.  52  are  marked  out  on  the  cheeks 
with  their  conjoint  pedicle  above  at  the  root  of  the  nose,  between 
the  two  inner  canthi,  extending  sufficiently  downwards  and  outwards 


*  This  should  he  refreslied.  The  above  account  is  taken  from  Stinisoii's  Operative 
Surgery,  p.  244. 

f  I  made  use  of  this  nietliod  in  the  case  of  a  Welsh  miner,  whose  nose  had  been  exten- 
sively destroyed  by  lupus,  aided  by  a  plaster  and  ointment  whicii  he  had  obtained 
from  a  quack  in  Carnarvon  for  the  payment  of  £5  7s.  6d.  The  bony  parts  were  almost 
intact,  but  the  soft  parts  and  cartilages  widely  destroyed.  The  resulting  nose  was 
prominent  and  shapely,  and  the  ultimate  scarring  very  slight. 


REPAIR   OF    NOSE.  257 

upon  the  cheek  to  secure  sufficient  ampleness  for  the  new  nose,  ac- 
cording to  careful  measurements  already  taken.  The  old  nose  being 
got  ready  by  careful  paring,  the  flaps  thus  marked  out  are  dissected 
up  and  united  in  the  middle  line  by  three  or  four  sutures,  while  the 
outer  margins  are  fixed  on  each  side  to  the  raw  surface,  at  a  proper 
distance  from  the  nasal  orifice.  Mr.  Bell*  advises  that  if  any  part  of 
the  old  sei^tum  remain,  it  should  be  made  very  useful  as  a  fixed 
point,  a  straight  needle  being  thrust  through  one  flap  close  to  its 
outer  lower  edge,  then  through  the  septum,  and  out  at  a  correspond- 
ing point  of  the  other  flap.  The  edges  of  the  wounds  left  in  the 
cheeks  can  generally  be  partially  united  by  sutures  of  silver  or  fishing- 

FiG.  52. 


(Bell.) 
(Syme.) 

gut,  and  the  triangular  portion,  which  must  be  left  to  heal  by  granu- 
lation, proves  an  advantage,  as  by  its  depression  it  enhances  the  ap- 
parent height  and  prominence  of  the  new  organ.  The  cavity  of  the 
new  nose  may,  for  the  first  few  days,  be  kept  gently  distended  with 
strips  of  iodoform  or  sal-alembroth  gauze,  and  later  on  with  small 
pieces  of  Jacques'  catheter  on  either  side. 

(3.)  The  Frontal  or  Indian  Method.f — This  method  should  be 
used  when  the  soft  parts  of  the  cheeks  are  insufficient,  when  they  are 
too  cicatricial,  or  when  an  operation  making  use  of  them  has  failed. 
Its  chief  objections  are  the  large  frontal  scar,  and  the  liability  of  the 
single  flap,  though  abundant^  and  prominent  at  first,  to  shrink  and 
fall  in  later  on. 

A  piece  of  gutta-percha  or  leather  is  so  cut  that,  when  folded,  it  is 
of  suitable  shajDC  and  size  for  the  new  organ ;  it  is  then  laid,  opened 
out,  upon  the  forehead,  and  the  dimensions  marked  out  with  an  ani- 
line pencil  or  tincture  of  iodine.  The  flap  thus  drawn  should  be  of 
the  shape  in  Fig.  54,  and,  owing  to  the  retraction  of  the  skin,  should 

*  Manual  of  Surgical  Operations  (4th  edition),  p.  176. 
f  Introduced  into  European  surgery  by  Mr.  Carpue  in  181  J. 
17 


258 


OPERATIONS  OX  THE  HEAD  AND  NECK. 


measure  J  of  an  inch  more  than  the  model  in  every  direction.     The 
average   dimensions  of  the  flap  are  thus  given  by  Mr.   Erichsen :  * 


Fig.  54. 


Flaps  from  forehead.     Also  flaps  from  cheeks.    (Skey.) 

•when  the  whole  nose  requires  restoration,  it  is  usually  necessary  to 
make  it  about  21  to  3  inches  long,  and  from  3  to  3?  inches  wide  at  its 
broadest  part. 

For  the  frontal  flap  thus  mapped  oat,  a  bed  is  now  prepared  by 
paring  the  old  nose  into  a  raw,  triangular  surface ;  in  doing  this  the 
knife  must  be  used  obliquely,  cutting  from  without  inwards  towards 
the  middle  line,  so  as  to  leave  a  grooved  surface  sloping  inwards.  The 
warning  of  Erichsen  iloc.  supra  cit.,  p.  609)  should  here  be  remembered, 
not  to  remove  the  parts  too  widely,  lest  the  cheeks  later  on  retract  and 
flatten  out  the  nose.  The  bleeding  being  arrested  by  sponge-pressure, 
torsion,  leaving  on  Spencer  Wells's  forceps  (but  not  in  this  case  by 
ligature),  and  the  raw  surface  covered  over  with  lint  wrung  out  of 
warm  boracic  acid  lotion,  the  frontal  flap  previously  mr  rked  out  may 
now  be  raised.  This  is  done  by  running  a  scalpel  down  to  the  perios- 
teum, along  the  traced  line,  taking  care  that  the  pedicle  should  be 
sufficiently  long  to  bear  a  little  twisting,  and  sufficiently  broad  and 
thick  to  secure  the  presence  of  one  if  not  both  of  the  frontal  arteries. 


Su7-(j.,  vol.  ii.  p.  603. 


REPAIR    OF    NOSE.  259 

To  avoid  any  risk  of  stoppage  of  its  blood-supply  and  slougliing,  it  is 
well  to  place  the  incision  for  the  pedicle  a  little  obliquely,  with  one 
side  descending  a  little  lower  than  the  other — viz.,  on  the  side  to 
which  the  flajD  is  to  be  twisted.  Where  the  level  of  tlie  liairy  scalp 
admits  of  it,  this  flap  should  lie  a  little  obliquel}-,  the  tension  being 
thus  rendered  a  little  less.  Where  necessary,  the  flap  may  be  taken 
transversely  above  one  or  other  eyebrow,  but  the  objection  to  this  is, 
that  the  retraction  of  the  scar  upon  the  forehead  draws  the  corre- 
sponding eyebrow  upwards.*  The  frontal  flap,  however  placed,  is 
now  raised  from  below  upwards,  so  that  the  necessary  hemorrhage  is 
rendered  as  little  embarrassing  as  possible,  and  with  as  little  handling 
or  pinching  of  the  forceps  as  possible.  The  knife  should  be  kept  awdy 
from  the  flap  towards  the  periosteum,  and  used  in  the  same  plane 
throughout,  without  any  scoring  whatever.  The  haemorrhage,  free  at 
first,  is  readily  arrested  by  forcipressure  (leaving  on  Spencer  Wells's 
forceps  for  a  wliile),  or  by  sponge-pressure.  The  flap,  being  sufficientlv 
raised  to  hang  freely  and  without  tension,  is  then  twisted  slightly  to 
one  side  (that  on  which  the  pedicle  has  been  cut  longest),  and  brought 
down  and  adjusted  to  the  pared  edges  below  by  means  of  numerous 
fine  sutures  of  salmon-gut,  fine  silk,  or  wire,  a  few  of  chromic  gut 
being  interspersed,  and  all  introduced  with  very  fine  needles  on  a 
holder. 

If  the  condition  of  the  forehead  has  admitted  of  taking  a  columella 
from  these,  an  appropriate  groove  must  also  have  been  cut  in  the 
upper  part  of  the  median  line  of  the  lip,  and  the  tAvo  carefull}^  ad- 
justed. If  no  columella  can  be  taken  from  the  forehead  the  upper 
lip  must  furnish  it,  either  now,  if  the  patient's  condition  admits  of  it, 
or  later  on,  wlien  the  pedicle  of  the  frontal  flap  is  divided.  If  no 
columella  is  made  now,  the  flap,  when  attached,  must  l)e  supported 
by  gently  introducing  strips  of  some  antiseptic  gauze,  Avell  coated 
with  eucalyi)tus  and  vaseline  (5J~5J)  ointment.  If  a  columella  is 
made,  two  bits  of  drainage-tube  or  Jacques'  catheter  are  introduced. 
The  parts,  being  smeared  with  the  above  ointment,  are  well  covered 
in  with  aseptic  gauze  or  salicylic  avooI,  but  in  keeping  these  in  jjosi- 
tion  no  pressure  must  be  made  with  bandages  on  the  new  nose. 

The  forehead  wound,  on  which  sponge-pressure  has  been  made,  is 
now  partially  closed  with  one  or  two  hare-lip  pins  and  sutures,  but  in 
introducing  these  great  care  must  be  taken  not  to  constrict  the  pedicle 
of  the  frontal  flap.  Later  on,  healing  may  be  here  promoted  by  skin- 
grafting. 

The  chief  points  in  the  after-treatnient  are  not  to  change  the  dress- 
ings too  frequently,  and  to  use  the  utmost  gentleness  in  doing  so,  to  re- 

*  Stitnson,  loc.  supra  cit.,  p.  249. 


260  OPERATIONS    OX    THE    HEAD    AND    NECK. 

move  the  sutures  gradually,  and  to  be  on  guard  to  prevent  the  onset  of 
erysipelas,  or  of  secondary  haemorrhage.  The  former  will  be  known 
by  a  sudden  rise  of  temperature,  vomiting,  or  nausea,  and  is  best 
treated  l)y  warm  boracic-acid  lotion,  applied  l)y  a  mask  of  boracic-acid 
lint,  and  by  a  sharp  purge.  Haemorrhage  may  occur,  according  to 
Erichsen,*  ms  late  as  the  ninth  day.  It  must  be  met  by  careful  plug- 
ging Avith  aseptic  gauze,  dusted  with  iodoform  and  tannic  acid. 

The  flap  remains  for  some  time  swollen,  and  (edematous,  but  if  not 
going  to  slough,  it  will  found  warm  and  sensitive.  If  too  much  swell- 
ing persist,  leeches  or  careful  scarifications  should  be  made  use  of. 

Separation  of  the  root  of  the  flap. 

'  A  month  or  six  weeks  after  the  first  operation,  when  the  blood  sup- 
ply to  the  flap  in  its  new  position  is  established,  the  pedicle  is  divided 
with  a  narrow  straight  bistoury  and  cut  somewhat  wedge-shaped, 
with  the  apex  upwards,  an  appropriate  resting-place  being  fashioned 
for  it  in  the  skin  beneath,  which,  up  to  this  tiine,  has  not  been  touched. 
The  fine  sutures  already  mentioned  are  then  inserted. 

If  the  patient's  condition  has  been  feeble,  or  if  the  tissues  at  the 
sides  are  very  cicatricial,  and  thus  the  new  blood  supply  to  the  frontal 
flap    be   insufficient,  some    sloughing    may  take    place,  l)ut    this   is 

rare. 
Formation  of  a  new  columna. 

If  this  was  not  made  at  the  time  of  the  first  operation  it  should  be 
done  at  the  same  time  that  the  pedicle  is  divided.  It  is  rare  that  a 
forehead  is  sufficiently  high  to  obtain  an  adequate  columna,  and  the 
additional  thickness  and  vascularity  of  the  lip  make  it  much  more 
desirable  to  take  one  from  here.  Two  assistants,  with  a  finger  and 
thumb  at  each  angle  of  the  mouth  controlling  the  coronary  arteries, 
and  at  the  same  time  making  the  parts  tense,  the  surgeon,  with  a 
straight,  narrow  bistoury,  transfixes  the  root  of  the  lip  just  to  one 
side  of  the  middle  line  and  cuts  straight  down  through  the  free  border, 
a  similar  incision  is  made  on  the  opposite  side  of  the  middle  line,  and 
a  narrow  strip,  about  4  inch  in  width,  is  thus  detached  save  above. 
It  is  well,  in  a  man,  to  shave  off  the  skin  and  hair  follicles,  and  the 
tip  being  pared,  and  the  remains  of  the  old  columna  appropriately 
freshened,  the  fra-num  is  freely  divided,  and  the  new  columna  united 
to  the  remains  of  the  old  and  to  the  ahe  by  one  or  two  fine  sutures. 
The  cut  surfaces  of  the  lip  are  then  brought  most  accurately  into  ap- 
position with  a  silver  wire  suture  opposite  to  the  coronary  arteries, 
and  several  points  of  fine  silk  and  fishing  gut.  A  few  more  are  next 
inserted  to  further  adjust  the  columna. 


*  Loc.  supra  cit.,  \>.  611,  is  mentioned  a  case  of  Lister's,  in  which   hremorrhage  took 
place  on  the  nintii  day,  the  patient  k)sin<!;  over  a  pint  of  blood. 


REPAIR    OF    NOSE.  261 

(4.)  Italian  or  Tagliacotian  Method.— This  is  but  very  rarely 
made  use  of  in  this  country,  owing*  to  the  irksonieness  which  the 
needful  position  entails,  and  the  need  of  a  complicated  special  ap- 
paratus. 

On  the  other  hand,  the  absence  of  any  additional  scars  on  the 
forehead  and  cheeks,  and  tlie  abundant  flap  which  can  always  be 
obtained,  are  so  important  that  it  may  be  thought  worth  while  to  try 
this  method  in  female  patients  who  have  sufhcient  time  and  means, 
and  who  will  put  up  with  the  inconvenience  of  cramped  restraint  for 
two  or  three  weeks. 

Sir  W.  MacCormac  brought  a  case  before  the  Clinical  Societyf  in 
Avhich  this  method  had  answered  well  in  a  girl  aged  sixteen.  The 
following  account  is  taken  from  his  paper.  Means  for  keeping  the 
patient's  arm  in  the  needful  position  for  the  requisite  period  were 
thus  provided  :  "  A  pair  of  ordinary  stout  well-fitting  stays  were  first 
procured,  to  which  were  attached  two  perinteal  straps,  to  prevent  dis- 
placement upwards.  A  helmet,  partly  made  of  leather,  was  con- 
nected with  the  stays  by  a  leather  band  running  up  the  centre  of  the 
neck  and  back.  A  leather  armpiece,  strengthened  by  a  steel  band, 
was  moulded  so  as  to  extend  from  the  wrist  to  the  shoulder,  where  it 
was  buckled  to  the  stays.  The  wrist  and  hand  were  fastened  to  the 
helmet  by  a  gauntlet,  while  the  elbow  could  be  fixed  steadily  in  any 
required  position  by  straps  running  from  it  to  the  stays,  and  to  the 
sides  of  the  headpiece,  so  that  there  Avas  nowhere  any  undue  strain, 
the  pressure  being  so  evenly  distributed  that  each  strap  Avas  almost 
slack.  This  apparatus  was  next  applied  for  some  days  beforehand,  so 
that  any  point  of  undue  pressure  might  be  remedied.  The  girl  was 
able  to  sleep  soundh'  in  it,  and  it  gave  promise  of  proving  perfectly 
efficient. 

"Meanwhile  I  modelled  on  the  deficient  nose  a  gutta-percha  sub- 
stitute, and  from  this  Avas  able  to  project  on  a  flat  surface  the  extent 
of  the  deficiency. 

"  The  first  part  of  the  operation  was  performed  thus :  A  flap  Avas 
marked  out  on  the  inner  aspect  of  the  left  vipper  arm,  more  than 
double  the  actual  size  of  the  estimated  deficiency.  The  left  arm  was 
the  one  chosen  to  supply  the  flap,  and  the  right  side  of  the  nose  the 
one  first  operated  on.  the  septum  being  fashioned  at  the  same  time. 
The  flap  was  left  attached  to  the  upper  part  of  the  arm  by  a  broad 
long  pedicle,  and  so  arranged  that  there  should  be  no  traction  Avhat- 

*  In  cases  where  tlie  destruction  is  very  great,  where  other  methods  have  failed, 
where  the  skin  available  on  the  face  is  much  scarred  or  of  doubtful  soundness,  the 
Tagliacotian  method  is  especially  indicated. 

t  Clin  Soc  2rcnis.,\o\.  X  p.l81.  Three  figures  are  given,  of  the  patient  before  and 
after  the  operation,  and  of  the  apparatus  used. 


262  OPERATIONS    ON    THE    HEAD    AND    NECK. 

ever  upon  it,  whilst  the  raw  surface  from  which  it  was  taken  should 
be  accessible  for  daily  dressing.  With  the  flap  I  dissected  up  the 
subcutaneous  fat  down  to  the  muscular  sheath.  Immediate  retract- 
ion both  of  the  flap  and  of  the  denuded  part  of  the  arm  took  place  to 
a  large  extent,  so  that  the  raw  surface  on  the  latter  was  almost  co- 
extensive with  the  whole  inner  surface  of  the  girl's  arm,  the  flap  ap- 
pearing quite  small  in  comparison. 

"  I  now  made  a  slightly  curved  incision,  nearly  })arallel  to  the  free 
border  of  the  nose  on  the  right  side,  and  about  three  lines  above  it, 
corresponding,  in  fact,  to  where  the  alar  furrow  should  normally 
exist.  Tins  incision  was  prolonged  some  little  distance  into  the  cheek 
in  the  line  of  the  cheek  furrow,  whilst  the  remains  of  the  septum  were 
split  open  in  the  median  line.  This  nasal  flap  could  now  be  turned 
down  so  as  to  become  horizontal,  or  rather  a  little  depressed  below 
the  horizontal  line,  to  allow  for  retraction  of  the  ingrafted  piece.  A 
triangular  gap,  the  apex  pointing  towards  the  cheek,  was  thus  left 
exposed  on  the  right  lateral  aspect  of  the  nose,  and  into  this  the  trian- 
gular-shaped piece  from  the  arm  was  inserted,  and  accurately  attached 
by  suture,  the  portion  to  form  the  septum  being  sutured  in  the  groove 
already  formed  by  splitting  the  septum.  In  this  way  there  was  no 
paring  of  edges,  nor  was  a  single  particle  of  nose  tissue  sacrificed, 
whilst  by  having  so  large  a  line  of  attachment,  being  almost  sur- 
rounded by  living  tissue,  the  new  flap  was  much  more  likely  to  ad- 
here satisfactorily  in  the  first  instance,  and  from  its  freer  blood  supply 
less  prone  perhaps  to  subsequent  contraction."  Union  took  place  in 
great  part  by  first  intention,  some  suppuration  setting  in  on  the  eighth 
day,  owing  to  the  indifferent  plastic  power  of  the  subcutaneous  fat. 
Healing  was  not  complete  for  nearly  three  weeks.  At  this  date  the 
operation  was  completed  by  detaching  the  flap  from  the  arm,  cutting 
this  so  as  to  give  it  a  triangular  shape,  and  preparing  the  left  side  of 
the  nose  to  receive  it  in  a  manner  precisely  similar  to  the  right.  The 
perfect  vitality  of  the  now  completely  severed  tissue  of  the  arm  was 
made  apparent  by  copious  haemorrhage,  and  healing  was  complete  in 
a  fortnight. 

After  the  first  forty-eight  hours  scarcely  any  inconvenience  was 
felt  from  the  apparatus,  save  for  a  slight  excoriation  on  one  shoul- 
der. 

The  result  was  good,  but  it  was  expected  that  further  contraction 
Avould  much  improve  the  aspect  of  the  nose,  the  new  organ  being  fully 
large. 

Causes  of  failure  after  Complete  Rhinoplasty. 

1.  Gangrene  and  sloughing. 

2.  Secondary  haemorrhage. 

3.  Erysipelas, 


REPAIR    OF    XOSK. 


263 


4.  Destruction  of  the  new  nose  by  recurrence  of  the  old  disease. 

5.  Too  large  a  nose. 

6.  Too  small  a  nose. 

B.  Operations  for  Partial  Eestoration  of  the  Nose.— 

These  are  very  numerous  and  ha\-e  usually  been  designed  for  special 
cases.     A  few  only  will  be  alluded  to  here. 

(i)  Two  Lateral  Flaps. — This  method  is  indicated  when  the 
lower  third  of  the  nose  is  left  untouched  and  the  central  portion  espe- 
cially destroyed,  (a)  Small  square  flaps  are  raised  and  united  in 
the  middle  line  (Fig.  55).  (/?)  Another  method  is  shown  in  Fig.  54. 
It  was  made  use  of  by  Mr.  Skey  *  who  thus  describes  it :  "  In  cases  in 
which  the  ossa  nasi  are  destroyed,  the  operation  consists  in  bringing 
to  the  mesial  line  two  lateral  flaps  made  from  the  side  of  the  nose 
upon  the  cheek.     The  calculations  in  this  operation  are  nearly  as  im- 


Ficx.  o.- 


Fio.  56. 


Fig.  57 


Rhinoplasty.  Double  square  lateral 
flaps.     (Stimson.) 


Rhinoplasty.    Single  lateral  flap. 
(Stimson.) 


Rhinoplasty.    Denonvillier.s' 
method.    (Stimson.) 


portant  as  in  the  frontal  method.  An  incision  is  commenced  at  tlie 
root  of  the  nose,  as  nearly  as  possible  on  the  dorsum,  and  carried 
down  as  close  to  the  line  of  the  former  organ  as  the  condition  of  the 
skin  will  permit,  and  a  second,  commencing  5  inch  on  the  outer  side, 
should  extend  downwards,  curving  at  the  same  time  a  little  outwards, 
to  avoid  the  orbicularis.  The  second  incision  should  diverge  from 
the  first  towards  the  cheek-bone,  and  at  its  extremity,  which  should 
correspond  with  the  line  formed  by  the  base  of  the  nostril,  should  be 
distant  more  than  a  full  inch  from  it."  Mr.  Skey  advises  that  the 
columella  be  made  at  the  same  time,  attached  to  one  of  the  flaps  as 
shown  in  Fig.  54.  If  this  fail,  the  lip  will  still  serve  the  surgeon's 
purpose. 


Operative  Surgery,  p.  523. 


264  OPERATIONS    ON     IHE    HEAD    AND    NECK. 

(ii.)  Single  Lateral  Flap. — Tliis  may  be  taken  in  many  different 
ways  : 

(a)  From  the  cheek,  at  the  side  of  and  below  the  nose  (Fig.  56,  a). 

(/?)  From  the  opposite  side  (Langenbeck).  The  apex  of  the  flap  is 
left  attached  to  the  inner  angle  of  the  eye,  on  the  same  side  as  the 
deficiency,  while  the  base  comes  from  the  ala  of  the  sound  side  (Fig. 
56,  b). 

(y)  M.  Denonvilliers'  method.  A  border  that  has  already  cicatrized 
is  made  use  of  so  as  to  prevent  subsequent  narrowing.  A  triangular 
flap  is  marked  out  by  incisions  shown  in  Fig.  57,  the  pedicle  being 
internal.  The  flap,  having  been  carefully  raised  with  a  strip  of  carti- 
lage in  its  lower  margin,  is  displaced  downwards  into  position. 

In  all  the  above  methods,  if  cartilage  is  not  excluded  in  tlie  free 
border  which  is  to  form  the  new  ala,  the  flaps  should  be  cut  long 
enough  to  allow  of  turning  this  border  upon  itself  and  thus  giving  a 
thicker  and  more  natural  appearance  to  it. 

(d)  M.  Weber's  method.  The  flap  is  taken  from  the  upper  lip  : 
on  account  of  the  hair  follicles  this  plan  is  best  suited  to  women.  An 
oval  flap  is  taken,  usuall}^  from  the  centre  of  the  lip,  with  its  pedicle 
left  attached  close  to  the  columna  and  its  free  margin  reaching  to  the 
prolabium.  The  flap,  which  consists  only  of  part  of  the  thickness  of 
the  lip,  is  turned  up,  and  stitched  to  the  remains  of  the  ala,  which 
have  been  refreshed.  In  three  or  four  weeks  this  pedicle  is  divided, 
and  may  be  so  united  to  the  inner  surface  of  the  flap  as  to  give  it  a 
thicker  and  rounded  margin.* 

ROUGE'S  OPERATION.f 

Indications. — Whenever  the  surgeon  desires  to  gain  free  access  to 
the  nasal  cavities,  as  in  cases  of — 

1.  Intractable  ozana.J  Thus,  when  previous  persevering  treatment, 
including  Thudichum's  douche,  fails  to  cure  cases  of  strumous  ozsena, 
with  ol^stinate  inspissated  crusting  of  discharge  under  the  turbinated 
bones ;  when  dead  bone  is  detected  by  a  probe,  or  is  believed  to  be 
present  in  these  cases,  or,  more  commonly,  in  those  of  syphilitic 
ozaena. 


*  For  the  account  of  tliese  lateral  flap  operations  and  for  Figs.  55,  56,57,  I  am 
indebted  to  Dr.  Stinison's  Operative  Surgery,  p.  240. 

t  Nouvelle  Methode  pour  le  Traitement  chirurgical  de  r Ozhie,  par  le  Dr.  Rouge.  Lau- 
sanne :  1873. 

X  Mr.  Hayward  {Syst.  of  Surg.,  vol.  ii.  p.  644)  believes  tliat  in  a  large  nund)er  of 
cases  of  ozsena  the  discharge  is  due  to  a  carious  surface  being  present  on  the  base  of 
the  skull.  If  this  view  is  correct,  it  obviously  points  to  not  putting  off  this  operation 
too  late. 


REMOVAL   OF    NASAL    POLYPI.  265 

2.  In  inveterately  recurring  nasal  polypi,  persisting  after  the  steps 
advised  at  p.  266. 

3.  In  some  cases  of  naso-i)haryngeal  polypi — viz.,  where  the  growth 
is  small,  and  where  a  scar  is  especially  deprecated. 

Operation. — An  anaesthetic  having  been  administered,  th^surgeon 
must  decide  as  to  what  steps  he  will  take  to  prevent  the  blood  from 
getting  down  into  the  pharynx.  This  may  be  done  eitlier  by  plugging 
the  posterior  nares,  or  by  performing  laryngotomy  and  plugging  the 
fauces  with  a  sponge  (wfra).  If  the  haemorrhage  is  likely  to  be 
troublesome,  and  the  operation  prolonged,  I  much  prefer  the  latter 
precaution,  for  1  have  found  that  when  the  nostrils  are  plugged  it  is 
quite  possible  to  sever  the  silk  on  one  side,  owing  to  its  being  hidden 
by  clots,  and  its  whereabouts  thus  not  seen.  A  preliminary  laryngot- 
omy followed  by  plugging  the  fauces  does  away  with  the  trouble  of 
plugging  the  posterior  nares  and  with  the  presence  of  silk  ligatures  in 
the  nostrils.* 

The  upper  lip  having  oeen  well  raised  and  everted  by  an  assistant 
taking  hold  of  it  at  the  angles  of  the  mouth,  the  surgeon  frees  it  from 
the  upper  jaw  by  an  incision  through  the  mucous  membrane  reaching 
from  the  bicuspid  teeth  on  one  side  to  their  fellows.  In  doing  this 
the  knife  should  be  kept  close  to  the  bones  and  parallel  with  them. 
The  cartilaginous  septum  is  next  detached  from  the  anterior  nasal 
spine,  and  the  lower  lateral  cartilages  from  the  upper  jaw,  the  adja- 
cent parts  of  the  cheek  being  also  freed  at  the  same  time  sufficiently 
to  admit  of  the  nose  and  lips  being  lifted  up  sufficiently  to  explore 
the  nasal  cavities. 

After  any  dead  bone  has  been  removed,  the  sharp  spoon  applied, 
and  the  nasal  cavities  thoioughly  cleansed  in  cases  of  oza?na,  or  any 
polypi  dealt  with,  the  parts  are  replaced  (without  sutures),  and  iced 
boracic-acid  lint  applied  for  a  day  or  two,  till  the  pain  and  swelling 
have  su])sided,  and  the  risk  of  erysipelas  has  gone  by. 

Other  operations  on  the  nose — e.g.,  those  of  Lawrence  and  Oilier, 
are  given  later  on  under  the  heading  of  Naso-pharyngeal  Polypi,  pp. 
285,  286. 

REMOVAL  OF  NASAL  POLYPI. 

Some  six  years  ago  I  learnt  from  Mr.  M.  Banks  his  method  of 
clearing  out  the  nose  in  the  most  troublesome  cases.  I  have  used  it 
since  repeatedly  with  good  results,  and  believe  that  in  its  thorough- 
ness, the  simplicity  of  the  instruments  required,  it  is  far  superior  to 
snare,  injection  with   iron  perchloride,  etc.,  and  the  galvanic  loop. 

*  Plugging  the  fauces  after  a  laryngotomy  has  the  further  advantage  of  leaving  the 
posterior  nares  free  for  examination  by  a  finger  pavised  from  the  mouth,  a  point  of 
importance  in  examining  these  parts,  or  in  manipulations  in  the  case  of  a  polypus. 


266  OPERATIONS    ON    THE    HEAD    AND    NECK. 

Of  the  above,  the  first  is  an  excellent  means  of  getting  rid  of  the  larger 
polypi  which  come  down  first,  but  it  is,  I  think,  tedious  and  inefficient 
in  the  case  of  the  crops  of  the  smaller  ones,  often  sessile,  which  make 
their  appearance  later  on.  I  have  never  found  that  the  abundant 
haemorrhage  causes  any  serious  trouble,  as  long  as  the  assistant  who 
administers  the  anaesthetic  knows  his  business,  and  as  long  as  the 
patient's  head  is  kept  on  cne  side,  over  the  edge  of  a  table  or  sofa, 

Mr.  Banks's  method  is  given  in  his  own  words  :* 

"As  to  the  most  permanentl}^  curative  operation  for  nasal  mucous 
pol^^pi,  I  believe  there  is  nothing  equal  to  the  use  of  the  forceps  j^rop- 
erly  managed.  Where  there  are  large  isolated  polypi  with  well- 
marked  stalks,  the  wire  snare  or  Dr.  Thudichunj's  process  may  do  well 
enough,  and  probably  removes  them  with  much  less  pain  than  the 
forceps.  But  these  are  not  the  most  common  cases.  On  the  contrary, 
they  are  usually  crops  of  small  growths  fringing  the  superior  and 
middle  turbinated  bones,  which  no  snare  can  get  hold  of,  and  which 
in  due  time  make  their  appearance  as  large  ones.  Mr.  Syme,  after 
great  experience,  used  to  say  that  the  only  way  was  to  get  one  blade 
of  the  forceps  beneath  the  turbinated  bone  and  the  other  on  the 
opposite  side  of  it,  and  to  carry  away  as  much  bone  as  possible.  This 
I  always  endeavor  to  do,  and  find  that,  along  with  the  big  ones,  I 
have  brought  away  whole  crops  of  minute  polypi  just  commencing 
their  existence,  which  can  only  be  removed  by  carrying  away  the  bone 
from  Avhich  they  grow.  As  to  necrosis  and  all  sorts  of  contingencies 
which  it  is  said  may  occur  as  a  result  of  such  rough  surgery,  the 
simple  answer  is.  They  don't  occur.  On  the  other  hand,  the  patient 
has  a  chance  of  getting  rid  of  the  source  of  his  trouble,  and  does  not 
need  to  come  every  two  or  three  years  to  have  a  fresh  assault  made 
upon  a  fresh  lot.  Failure  often  results  from  using  forceps  wliich  are 
too  big  in  the  blades,  and  which  are  only  toothed  in  the  points  instead 
of  all  the  way  down.  In  not  a  few  cases,  where  the  patient  has  had 
several  operations  performed  previously  by  other  surgeons,  I  liave 
simply  smashed  up  the  whole  turbinated  bone  as  widely  as  I  could, 
and  so  have  settled  the  matter  permanently.  Now  the  pain  and 
dreadful  sensations  produced  by  this  proceeding  are  more  than  mor- 
tals can  bear,  and  so  the  patients  have  had  chloroform  or  ether,  and 
it  would  be  an  excellent  thing  if  this  were  resorted  to  more  frequently. 
Even  a  moderate  assault  with  the  forceps  is  a  most  horrid  process, 
and  patients  who  have  gone  through  it  once  or  twice,  will  endure  any 
amount  of  chronic  misery  rather  than  face  it  again.  But  only  a  very 
few  surgeons  seem  inclined  to  give  these  unfortunates  an  ana\sthetic, 
urging  as  their  reasons  the  danger  of  blood  going  down  the  throat  and 

*  Clin.  Notes  upon  Two  Years'  Surgical  Work  in  the  Liverpool  Royal  Infirmary,  p.  180. 


EEMOVAL    OF    UPPER    JAW.  267 

chokino;  the  patient,  and  the  fact  that,  owing  to  the  patient  being 
insensible,  he  cannot  blow  down  the  nostrils  so  as  to  let  it  be  known 
whether  they  are  clear  or  not.  My  plan  is  to  have  the  patient  thor- 
oughly aneesthetized  on  a  sofa.  When  fully  insensible  his  head 
should  be  brought  over  the  edge  so  that  the  nostrils  are  dependent, 
and  then  the  surgeon,  kneeling  on  the  floor,  passes  up  the  forceps, 
and  pulls  out  everything  he  can  till  there  is  nothing  more  to  pull. 
Meantime,  all  the  blood  runs  out  of  the  nostrils,  and  none  need  go 
down  the  throat  at  all,  while  the  whole  time  necessary  for  a  thorough 
cleaning  is  about  a  minute  for  each  nostril.  I  feel  convinced  that,  for 
certain  cases,  the  only  satisfjictory  cure  is  to  pull  away  as  much  as 
can  be  got  of  the  superior  and  middle  turbinated  bones." 


CHAPTER  VII. 
OPERATIONS  ON  THE  JAWS. 

OPERATIONS  ON  UPPER  JAW. 

These  will  include — 

i.  Removal,  partial  or  complete,  for  growths  (Fig.  58). 

ii.  Operations  for  naso-pharyngeal  polypus  (Figs.  59,  60,  61). 

iii.  Opening  the  antrum. 

REMOVAL  OF  UPPER  JAW,  PARTIAL  OR  COMPLETE. 

Indications. — These  include  the  different  growths  to  which  the 
upper  jaw  is  liable,  and  opportunity  will  be  taken  here  to  give  briefly 
the  chief  practical  points  in  connection  with  these. 

1.  Epulis. — One  of  the  most  frequent  new  growths  met  with  here. 
Etjmiologically  gum  tumors,  these  growths  vary  a  good  deal.  At  first, 
and  most  frequentl}^  they  are  simply  fibrous,  tough  and  firm,  springing 
from  the  periosteum,  the  periodontal  membrane,  and  the  endosteal 
lining  of  an  alveolus.  Myeloid  cells  and  small  spicula  of  bone  are  not 
uncommon.  The  longer  they  are  left,  the  more  they  are  irritated, 
especially  with  imperfect  attempts  at  removal,  the  more  cellular  and 
allied  to  the  sarcomata  do  they  become. 

Very  rarely  on  drawing  the  tooth,  to  the  alveolus  of  which  the 
growth  is  connected,  the  epulis  comes  away  completely.  Much  more 
frequently  it  is  firmly  connected  to  the  periosteum  and  subjacent  can- 
cellous tissue,  or  the  endosteal  lining  of  one  or  more  alveoli.  Removal 
should  be  early  and  comi3lete.  Shaving  oft'  the  growth  and  the  gum 
beneath,  and  then  applying  caustics  to  any  suspicious  granulations, 
is  most  uncertain  and  unsatisfactory,  especially  if  the  presence  of  teeth 


268  OPERATIONS    ON    THE    HEAD    AND    NECK. 

is  allowed  to  interfere  with  the  complete  removal  of  the  jirowth,  or  if 
this  is  connected  with  stumps,  and  thus  dips  deeply  into  an  alveolus. 
By  far  the  l)est  treatment  is  to  draw  a  tooth  in  front  and  l)eliind  the 
growth,  and  then  with  a  narrow  saw  to  notch  the  hone  at  these  points 
deeply  through  the  alveoli ;  with  cutting  forceps  a  V-shaped  or  rect- 
angular piece  of  the  bone  is  then  removed.  The  drawing  of  teeth  not 
only  enables  the  surgeon  thoroughly  to  eradicate  the  growth,  but  their 
removal  leads,  as  })ointe(l  out  by  Mr.  Salter,*  to  wasting  of  the  alveolus 
and  thus  to  non-recurrence  of  the  growth.  The  teeth,  if  sound,  should 
be  preserved,  and,  later  on,  when  all  is  firmly  healed,  fitted  to  a  plate 
by  a  dentist.     The  deformity  is  thus  rendered  imperceptible. 

In  1884,  a  captain  in  the  Royal  Navy  whose  ship  Avas  on  the  North 
American  station,  came  under  my  care  with  an  epulis  connected  with 
the  lower  incisors  and  contiguous  alveolar  margin.  The  teeth  were 
all  ])reserved,  and  when  the  parts  Avere  soundly  healed  Mr.  Moon 
refitted  them  so  skilfully  that  no  trace  whatever  of  an  operation 
could  be  noticed,  and  the  use  of  a  speaking-trumpet,  which  was  most 
essential  in  this  case,  was  not  interfered  with. 

If  a  patient  refuse  the  only  operation  which  is  safe,  the  surgeon 
must  rest  satisfied  with  shaving  off  the  growth,  gouging  the  subjacent 
bone,  and,  if  needful,  applying  caustics  to  any  suspicious  patches  later 
on.  This  course  is  not  only  much  more  tedious  and  painful,  but  is 
uncertain  to  boot. 

2.  Fibroma. — These  originate  either  in  the  periosteum  or  in  the 
endosteum  of  the  antrum.  At  first  firm,  dense,  and  slow-growing, 
they  may,  from  the  frequent  irritation  inseparable  from  their  site, 
become  vascular,  sloughy,  and,  taking  on  more  rapid  growth,  tend  to 
invade  the  numerous  fossse,  fissures,  and  foramina  in  the  neighborhood 
of  the  bone.  They  should  be  attacked  early,  and  while  the  surgeon 
may  need  at  this  stage  to  remove  only  the  periosteum  and  bone  from 
which  the  tumor  springs,  especially  if  it  be  alveolar  in  origin,  or  after 
opening  the  antrum  to  shell  out  the  fibroma  completely,  he  must  also 
be  prepared  for  more  radical  measures,  especially  if  the  growth  is  of 
long  standing,  of  late  more  rapid,  if  the  patient  is  at  all  advanced  in 
years,  and  especially  if  the  growth  is  recurrent. 

3.  Sarcoma. — These  include  the  spindle,  round  and  myeloid  varie- 
ties, the  fibro-,  chondro-,  osteo-sarcomata,  and  the  rarer  form  of  alve- 
olar sarcoma.  While  the  more  slowly  growing  ones  simulate  and  may 
be  mistaken  for  more  innocent  growths,  such  as  epulis,  the  more  rapid 
ones  will  tax  the  surgeon's  judgment  as  to  whether  any  oiDcration  is 

*  System  of  Surgery,  vol.  ii.  p.  45f3.  Mr.  Salter  also  points  out  that  where  an  epulis 
forms  on  an  apparently  edentulous  part  of  tiie  jaw,  the  existence  of  stumps  should 
always  be  looked  for. 


REMOVAL    OF    UPPER   JAW.  269 

justifiable,  and  all  his  skill,  if  removal  is  attempted.     On  these  subjects 
the  reader  is  referred  to  pp.  271,  272. 

4.  Carcinomata. — At  the  present  time  the  softer  growths  which 
attack  the  jaAV,  and  were  formerly  called  medullary  cancers,  are  looked 
upon  as  rapidly  growing  sarcomata.  The  only  true  carcinomata  met 
Avith  here  are  epitheliomata.  These  are  usually  of  the  squam.ous  kind, 
and  commence  in  the  alveolar  border  in  ulceration,  beginning  in 
syphilis  or  the  irritation  of  an  ill-fitting  tooth-plate.  They  tend  to 
creep  far  back  and  to  invade  the  palate  and  tonsil,  on  this  account 
they  should  be  operated  on  early.  Whenever  a  sore  in  this  position 
is  suspicious  in  its  characters,  and  obstinate  to  treatment,  whatever  be 
the  age  of  the  patient,  the  parts  aff'ected  should  be  widely  and  freely 
extirpated.  If  the  growth  has  eaten  into  the  antrum  or  has  travelled 
back  so  as  to  invade  the  ptervgoid  region,  removal  of  the  whole  bone 
is  most  likely  to  benefit  the  patient  More  rarel}^  a  squamous  epithe- 
lioma attacks  the  jaw  from  the  lip  or  face.  This  happens  much 
more  often  in  the  case  of  the  lower  jaw.  Another  variety  of  epithe- 
lioma met  with  here  is  the  tubular*  variety  (cylindrical  or  adenoid 
carcinoma),  whi<?h  begins  in  the  mucous  membrane  of  the  antrum  or 
nose.  It  is  marked  by  rapidity  of  growth  and  invasion  of  the  sur- 
rounding parts,  and  is  thus  of  grave  prognosis. 

5.  Dentigerous  Cysts. — These  are  formed  by  a  collection  of  serous 
fluid  taking  place  during  the  development  of  a  tooth,  nearly  always  a 
permanent  one,  which  has  not  come  through.| 

There  are  two  varieties  of  these  cysts;  one,  the  commonest,  is  cj'sti'C 
only,  consisting  of  an  outer  bony  shell  of  varying  thickness  and  an 
inner  membranous  one.  The  tooth  may  be  well  formed  or  a  small 
shapeless  calcified  mass:  its  crown  usually  projects  into  the  sac,  ver- 
tically or  horizontally. 

The  following  points  are  of  practical  importance.  These  cystic 
swellings  may  be  taken  for  solid  growths,  but  this  mistake  may  be 
avoided  l>y  remembering  that  when  such  a  swelling  exists  there  is 
usually  a  history  of  its  having  commenced  in  early  life,  and  that 
though  all  the  teeth  may  appear  to  be  present,  one  will  very  likely  b« 

*  Mr.  Heath  (Diet,  of  Surg.,  vol.  i.  p.  857)  quotes  Rejhis  as  calling  tliis  form  epi- 
thelioma terebrant,  from  its  boring  or  burrowing  tendency. 

t  Mr.  Salter  {Syst.  of  Surg.,  vol.  ii.  p.  469)  gives  the  following  three  circumstances 
as  capable  of  producing  impaction  of  a  tooth :  (1)  The  tooth  may  be  originally  devel- 
oped too  deep  in  the  body  of  the  .jaw— thus,  though  it  grow  in  the  right  direction,  it 
will  never  reach  the  alveolar  margin  ;  (2)  while  it  may  be  sufficiently  superficial,  it 
takes  an  oblique  direction  of  growth,  so  that  it  lies  covered  more  or  less  in  the  axis 
of  the  bone;  (3)  the  position  of  the  tooth  and  its  line  of  growth  may  be  originally 
normal,  but  from  arrest  of  the  development  of  the  fang  it  may  fail  to  reach  the 
alveolar  edge. 


270  OPERATIONS    ON    THE    HEAD    AND    NECK. 

found  to  be  a  temporary  one.  Furthermore,  there  is  the  help  derived 
from  puncture  with  a  fine  trocar.* 

The  treatment  consists  in  exposing  the  surface  of  the  cyst  by  turning 
the  lip  up,  or  by  making  incisions  through  this  as  small  as  possible, 
then  in  cutting  away  freely  (with  bone-forceps  aided  by  a  f-inch  tre- 
phine if  needful)  the  walls  of  the  cyst,t  so  as  to  examine  its  contents, 
and  then  digging  out  the  tooth,  often  the  most  difficult  part  of  the 
operation.  The  cavity  is  then  carefully  stuffed  with  strips  of  aseptic 
gauze  to  encourage  its  granulating  from  the  liottom.  Later  on,  if  any 
swelling  persist,  keeping  up  deformity,  pressure  must  be  trusted  to, 
a  Hainsby's  truss  being  here  found  useful. 

In  the  other  variety  of  dentigerous  cysts,  solid  growth  of  a  sarco- 
matous nature  is  present  in  addition  to  the  cystic.  The  surgeon  here 
must  use  his  discretion  as  to  opening  the  cyst,  freely  scraping  out  the 
growth  and  then  applying  the  cautery  or  zinc-chloride  paste,  or  re- 
moving the  bone  itself.  If  the  case  is  of  any  duration,  if  the  growth 
is  soft  and  making  rapid  progress,  the  latter  course  will  be  the  wiser 
one. 

6.  Enchondromata. — These  are  rare.  They  seem  to  commence  in 
adolescence,  usually  starting  from  the  surface  of  the  bone,  c.g.^  the 
nasal,  or  from  the  antrum.  They  should  be  removed  early  and  com- 
pletely, as  they  grow  steadily,  involving  the  nose,  orbit,  frontal  sinuses, 
and  thinning  the  cranial  bones. ;{; 

7.  Osteomata. — These  are  rare  also.  Two  forms  occur:  (1)  of  the 
nature  of  an  ordinary  exostosis.  These  are  usually  cancellous,  but 
ivory  ones  arise  from  the  superior  maxilla  as  well  as  from  the  orbit 
and  frontal  sinuses.  Occasionall}^  they  are  symmetrical. §  Their 
growth  is  usually  slow.  If  they  occur  in  young  subjects  they  should 
be  attacked  while  small.  The  ivory  exostoses  are  occasionally  found 
loose  on  laying  open  the  antrum,  as  is  the  case  with  those  in  the 
frontal  sinuses.  (2)  Diffuse  osteomata.  These  are  intermediate  in 
hardness  between  cancellous  and  ivory  exostoses.  They  have  often 
broad,  ill-defined  bases,  and  are  often  multiple  and  symmetrical.     As 

*  Mr.  Fearn,  of  Derby,  was  candid  nnough  to  publish  a  case  of  this  mistake  in  diag- 
nosis in  the  case  of  the  lower  jaw,  Brit.  Med.  Journ.,  August  27,  1864.  The  specimen 
is  figured  in  Mr.  Heath's  Injuries  and  Diseases  of  (he  Jaws,  p.  162,  and  shows  well  how 
such  a  mistake  miglit  have  arisen. 

t  A  good  illustration  of  this  condition  will  be  found  in  Mr.  Bryant's  Surgery,  vol.  i. 
Fig.  194. 

%  Good  instances  of  what  these  enchondromata  may  come  to  are  given  by  Mr.  Mor- 
gan's case,  Guy's  Hasp.  Reps.,  1842;  Mr.  Heath's  Di.^cases  and  Injuries  of  the  Jaws,  p. 
237,  with  an  excellent  illustration,  Fig.  107. 

§  In  Ml'.  Hutchinson's  Clinical  Surgery,  vol.  i.  p.  11,  Figs.  3,  4,  will  be  found  admi- 
rable illustrations  of  symmetrical  exostoses  from  the  upper  jaw. 


REMOVAL    OF    UPPER    JAW.  271 

they  tend  to  produce  hideous  deforuiity,  and,  though  slowly,  most 
distressingly,  to  destroy  life,  they  should  be  attacked  while  small.  Mr, . 
Pollock  *  quotes  Mr.  Stanley  f  as  an  authority  for  the  fact  that  in  cases 
where  the  whole  mass  is  beyond  removal,  a  portion  may  be  cut  away 
with  present,  if  not  permanent,  benefit.  This  can  only  apply  to  osteo- 
mata  of  purely  hypertrophic  nature.  Where  the  bony  growth  is 
tipped  with  cartilage  every  atom  must  be  removed  for  the  operation 
to  be  of  any  benefit.  Well-made  osteotomes  and  drills  worked  by  a 
dentist's  instrument  may  be  of  much  service  here,  the  great  object 
being  to  drill  a  number  of  holes  in  different  directions  through  the 
growth,  and  then  to  cut  through  the  intervening  bone  with  well-made 
osteotomes  and  a  mallet.  One  of  the  chief  risks  is  that  of  intra-cranial 
inflammation,  especially  if  the  growth  has  involved  the  interior  of 
the  skull. 

Questions  arisivg  before  Attempting  Removal  of  the  Upper  Jaic. 

(i.)  Is  the  growth  cystic  or  solid  ? 

(ii.)  What  is  the  relation  of  the  growth  to  the  jaw?  Did  it  begin  on 
one  of  the  surfaces  of  the  jaw,  Avithin  the  antrum,  or  behind  the  jaw? 

(iii.)  Is  the  growth  one,  whether  malignant  or  not,  that  it  is  wise  to 
attempt  its  removal  ? 

(i.)  Is  the  Growth  Cystic  or  Solid?— Cases  already  quoted 
at  p.  270,  show  that  mistakes  may  arise  here.  Mr.  Heath  gives  a  case 
under  his  own  care  in  which  caseous  pus,  after  sup])uration  in  the 
antrum,  was  taken  for  a  solid  growth  and  the  jaw  removed.  As  the 
diagnosis  is  evidently  most  difficult  in  some  cases,  the  surgeon  should, 
in  all  cases  of  doubt,  explore  with  a  trocar  and  cannula,  a  drill  and 
brad-awl,  before  he  makes  incisions  whicli  may  be  quite  uncalled  for. 

(ii.)  What  is  the  Relation  of  the  Growth  to  the  Jaw  ?— Did 
it  begin  on  one  of  the  surfaces  of  the  jaw,  witliin  the  antrum,  or  behind 
the  jaw  ? 

In  some  cases  it  is  quite  impossible  to  be  sure  on  this  point  up  "to 
the  time  when  the  flaps  are  reflected,  or  till  the  jaw  itself  is  removed. 

The  following  points  may  be  useful  in  aiding  a  decision  as  to  the 
relation  of  the  growth  to  the  jaw  : 

If  the  growth  began  on  the  surface  of  the  jaw — e.g.,  the  nasal  or 
malar  process — there  will  probably  be  a  history  of  a  lump  noticed 
here  first,  very  likely  after  a  blow,  and  any  evidence  of  the  antrum, 
nose,  palate,  and  orbit  being  involved  will  be  deferred  till  late.  On 
lifting  up  the  cheek,  masses  of  growth  will  very  probably  l)e  found 
growing  down  between  the  cheek  and  gums,  but  not  altering  the  line 

*  SyKt.  of  Snrg.,  vol.  ii.  p.  535. 

t  Diseases  of  Bonci,  p.  5. 


272  OPERATIONS    ON    THK    HEAD    AND    NEt^K. 

or  affecting  the  structure  of  the  alveolus,  unless  it  commenced  in  it  or 
just  above  it. 

If  the  growth  began  in  the  antrum  the  cheek  is  more  slowly  swollen, 
and  the  swelling  is  deeper  and  less  defined.  The  different  walls  and 
boundaries  of  the  cavity — viz.,  the  orbital,  nasal,  facial,  and  zygomatic 
— are  expanded  steadily  and  with  a  varying  rapidity  ;  while  the  pal- 
ate is  depressed  and  the  alveolar  border  displaced  and  the  teeth  line 
rendered  irregular. 

If  the  growth  began  behind  the  antrum — g.//.,  in  the  basilar  process 
of  the  sphenoid,  or  the  pterygo-maxillary  fossffi — in  many  cases  a 
history  will  be  given  of  polypi  removed  from  the  nose  or  pharynx 
some  time  before,  perhaps  recurring  soon  ;  tbe  upper  jaw  is  pushed 
forwards,  and  in  some  cases  there  is  but  little  alteration  in  its  outward 
shape.  But  this  is  by  no  means  constant.  Not  unfrequently  the 
upper  jaw  will  be  so  altered  by  pressure,  its  processes — e.g.,  the  molar 
— so  thinned,  flattened,  and  expanded  that  it  may  well  be  thought 
that  the  disease  began  in  the  bone  itself.  And  this  mistake  is  the 
more  excusable  when  it  is  remembered  how  easily  a  growth  situated 
behind  the  antrum  may  make  its  way  into  this  cavity  either  by 
absorbing  its  walls  or  by  entering  it  through  the  opening  into  the  nose. 

If  the  growth  has  begun  behind  the  antrum,  starting  from  the  base 
of  the  skull,  symptoms  pointing  to  blocking  of  the  nose — viz.,  pain 
here,  in  the  orbit  and  brow ;  epiphora  from  blocking  of  the  nasal  duct, 
interference  with  nasal  breathing,  epistaxis,  etc. — will  most  })robably 
be  present,  yet  it  must  be  remembered  that  many  of  these  symptoms 
will  be  brought  about  by  a  growth  within  the  antrum  increasing 
rapidly. 

It  is  only,  I  think,  when  the  surgeon  finds  no  evidence  of  the  growth 
beneath  the  skin,  or  of  its  originating  on  the  surftice  of  the  bone,  no 
depression  of  the  palate,  and  no  irregularity  of  the  alveolar  margin, 
or  displacement  of  the  teeth,  that  he  can  say  that  the  growth  is  prob- 
ably behind  the  antrum. 

(iii.)  Is  the  Growth  one,  whether  Malignant  or  not,  that 
it  is  wise  to  Attempt  its  Removal  ? — ^Wliile  every  case  must 
be  decided  upon  separately,  and  while  it  would  be  most  al)surd  and 
misleading  to  lay  down  hard-and-fast  rules,  the  following  are  not 
unworthy  of  attention : 

Favorable  Cises. — Growths  with  a  duration  of  years,  not  months, 
hard,  well-defined,  limited  to  the  jaw,  and  the  skin  over  the  growth 
perhaps  thinned  from  pressure,  and  altered  in  color,  but  still  movable 
over  the  parts  beneath. 

Unfavorable  Ca^es. — History  of  a  few  months'  duration  ;  growth  soft, 
vascular,  ill-defined  ;  integuments  involved  and  fixed  ;  naso-pharynx 
invaded  ;  extension  into  orbit  or  temple — e.g.,  soft,  semi-elastic  swell- 


EEMOVAL    OF    UPPER    JAW.  273 

ing  noticed  behind  malar  bone  in  temporal  region ;  extension  to  the 
sub-maxillarv  and  cervical  glands ;  origin  of  the  growth  behind  the 
jaw,  rather  than  on  it,  or  within  the  antrum. 

Occasionally,  a  growth,  unfavorable  at  first  sight,  from  its  large  size, 
will  be  found  to  have  protruded  on  to  the  face  without  involving  the 
parts  around,  and  especially  those  behind. 

The  history  must  be  carefully  examined  into.  If  it  be  doubtful 
where  the  growth  began,  whether  it  has  invaded  or  only  crept  towards 
the  nostril,  the  surgeon  will  inquire  as  to  the  existence  of  deep-seated 
pain,  stuffiness  in  the  back  of  the  nose,  loss  of  smell,  interference 
with  nasal  respiration,  epistaxis,  etc.  Again,  the  existence  of  any 
swelling  near  the  inner  canthus  will  point  to  extension  towards  the 
ethmoid  and  base  of  tlie  skull. 

Complete  Removal  of  Upper  Jaw  (Fig.  58).— The  patient 

having  been  brought  carefully  *  under  an  anaesthetic,  and  duly 
propped  up,  the  face  shaved,  and  the  head  raised  and  turned  over 
towards  the  opposite  side,  the  surgeon  takes  this  opportunity  of 
exnmining  more  completely  the  attachments  and  limits  of  the  growth, 
and  decides  whether,  owing  to  its  vascularity,  it  will  be  wiser  to  jier- 
form  a  preliminary  laryngotomy  and  plug  the  back  of  the  pharynx, 
infra. 

The  incision,  which  goes  by  the  name  of  Sir  W.  Fergusson,t  is  then 
made  through  the  centre  of  the  lower  lip  (an  assistant  controlling 
the  opposite  coronary  while  the  one  in  the  flap  is  commanded  by  the 
surgeon  himself),  round  the  ala,  and  up  along  the  side  of  the  nose  to 
the  inner  canthus,  and  then  outwards  just  below  the  margin  of  the 
orbit,  as  far  as  the  malar  prominence.  The  flap  thus  marked  out  is 
then  reflected,  and  though  no  large  vessels  are  cut,  the  haemorrhage  is 
often  free,  especially  in  cases  of  rapidly  growing  tumors  which  have 
thinned  the  bone.  Spencer  Wells's  forceps  are  applied  to  the  larger  of 
these,  while  the  flap  is  being  reflected  these  are  secured,  and  an  assist- 
ant makes  siDonge-pressure  if  needful  upon  the  flap  to  arrest  oozing, 
while  the  surgeon  divides  the  bone  in  the  following  order,  the  ala  of 

*  As  ill  excision  of  tlie  tongue,  tiie  assistant  to  whom  tlie  ansestlietic  is  entrusted  is 
second  only  in  importance  to  the  surgeon.  He  should  watch  most  carefully  for  the 
first  signs  of  flagging  of  the  pulse,  and  meet  this  by  injections  of  ether  or  brandy. 
Any  evidence  of  blood  going  down  the  throat,  dyspnoea  (as  shown  by  venous  stasis  of 
the  cheeks),  lividity  of  the  lips,  or  respiration  short  and  fixed,  must  also  be  looked 
out  for. 

t  First  recommended  by  Dieffenbach.  Its  advantages  over  such  a  one  as  Lister's  are 
very  great — viz.  (])  only  the  terminal  branches  of  the  facial  nerve  are  divided ;  (2) 
only  branches  of  the  facial,  not  ils  trunk,  are  cut;  (3)  the  scar  left  is  much  less  con- 
spicuous, as  the  incisions  are  placed  in  the  natural  feature-folds. 

18 


274 


OPERATIONS    ON    THE    HEAD    AND    NECK. 


the  nose  being  first  detached  from  the  bony  margin,  and  the  perios- 
teum of  the  floor  of  the  orl^it  freed  : 

(1.)  Tlie  junction  of  the  jaw  with  the  malar  bone  is  divided.  The 
line  for  the  saw  is  marked  out  with  the  knife  upon  tlie  bone  just  in 
front  of  the  origin  of  the  masseter.  With  a  strong-backed  saw  (Fer- 
gusson's  or  Adams's  osteotomy  saw)  tins  line  is  converted  into  a  deep 
groove  and  the  rest  of  the  bone  quickly  severed  with  forceps,  the  left 
forefinger  placed  upon  the  margin  of  the  orbit  steadying  these  instru- 
ments and  preventing  any  damage  to  the  eye.  This  bone  section  is 
practically  in  a  line  with  the  spheno-maxillary  fissure  (at  the  lower 
and  outer  part  of  the  orbit),  and  should  fall  into  it. 

(2.)  The  nasal  process  of  the  superior  maxilla  is  next  severed  by 
cutting  a  saw-groove  across  it,  and  then  placing  one  blade  of  the  for- 
ceps inside  the  nostril  and  the  other  against  the  inner  angle  of  the 
orbit,  the  soft  parts  being  first  a  little  freed  and  carefully  kept  out  of 
the  way  with  the  left  thumb-nail. 

(3.)  The  central  or  a  lateral  incisor  being  next  drawn,  the  mouth 

is  widely  opened  with  a  gag,  and  an  incision  is  made  with   a  stout 

scalpel  along  the  middle  line  of  the  hard  palate  up  to  the  teeth,  and 

then  another  transversely  outwards  at  the  junction  of  tlie  hard  and 

soft  palate,  towards  the  molar  teeth   on  the  side  affected.     The  soft 

^      .„  palate  is  then  detached  with  a 

Fifi.  o8.  '■ 

scali)el  or  blunt-})ointed  scissors, 

and  til  us  preserved  when  the 
bone  and  growth  are  wrenched 
away.  The  hard  palate  is  then 
deeply  notched  with  the  saw 
introduced  through  the  nose 
opposite  to  the  tooth  which  has 
been  drawn,  and  severed  with 
bone-forceps,  one  blade  of  which 
is  introduced  within  the  nose, 
the  other  into  the  mouth.  If  a 
chisel  or  osteotome  is  now  in- 
serted into  the  different  lines  of 
bone  section,  the  bone  is  loosened 
with  a  series  of  quick  and  care- 
ful levering  movements,  while 
finally  lion-forceps  being  made  to  bite  firmly  into  the  hard  palate  and 
the  malar  aspect  of  the  bone  just  below  the  infra-orbital  foramen,  the 
bone  is  detached  by  a  few  wrenching,  rocking  movements  ujjwards 
and  downwards,  and  laterally,  while  tlie  left  forefinger  detaches  any 
soft  parts  whicli  retain  the  bone,  the  sujjerior  maxillary  nerve  being 
cut  cleanly  with  scissors. 


Removal  of  upper  jaw.    Reflection  of 
flap,  and  section  of  bones. 


REMOVAL    OF    UPPER    JAW.  275 

When  the  bone  has  been  much  invaded  by  disease,  oi*  in  the  case 
of  an  aged  dead  body,  it  is  very  hkely  to  come  away  fragmentarily, 
being  unavoidably  crushed  down  by  the  forceps. 

On  the  removal  of  the  bone,  the  pterygoid  fossae,  the  cavity  of  the 
nose  and  the  palate  are  examined,  and  the  sharp  spoon  applied  to 
remove  any  remaining  portions  of  disease,  or  Paquelin's  cautery 
made  use  of  to  destroy  any  of  these  which  cannot  be  otherwise 
removed. 

The  bleeding  is  seldom  free  at  this  stage,  save  in  rapidly  growing 
cases,  as  the  branches  of  the  internal  maxillary  are  small  before  they 
reach  the  tumor,  and,  as  they  are  torn  through,  it  is  usually  arrested 
by  firm  sponge-pressure. 

If  there  is  any  doubt  about  any  of  the  growth  being  left  behind, 
some  paste  of  zinc  chloride,  made  up  with  equal  parts  of  flour,  had 
best  be  inserted  on  lint  to  which  silk  is  attached,  the  threads  being 
brought  out  of  the  mouth  through  the  palate,  and  so  readily  removed 
in  a  few  days.  But  if  the  bone  has  come  away  with  all  the  growth,  if 
the  surface  of  this  is  smooth  and  encapsuled,  not  ragged  or  lacerated, 
the  surgeon  will  do  best  to  insert  nothing  into  the  cavity.  If  oozing 
is  going  on,  or  if  there  is  reason  to  fear  intermediary  hemorrhage, 
strips  of  iodoform  or  sal-alembroth  gauze  should  be  carefully  packed 
in,  and  removed  later  on  by  the  mouth.  But  it  is  difficult  to  keep  even 
these  sweet,  and  the  surgeon  will  do  best  to  dispense  with  any 
plugging  if  possible,  and  to  content  himself  with  brushing  over  the 
w'ound  with  a  solution  of  zinc  chloride  (gr.  xx-5j),  or  with  a  solution 
of  iodoform  in  ether.  The  edges  of  the  Avound  are  then  brought 
together  with  a  few  points  of  silver  suture,  one  or'  two  of  these  being 
always  inserted  in  the  lip,  and  others  of  gut,  or  horse-  hair,  or  carbol- 
ized  silk.  Esjjecial  care  should  be  paid  to  adjusting  the  red  line.  A 
little  iodoform  is  then  dusted  on  and  gauze  dressings  with  salicylic 
wool,  or  a  pad  of  boracic-acicl  lint  wrung  out  of  the  saturated  lotion, 
and  kept  constantly  moist,  applied. 

During  the  after-treatment  the  patient  should  be  kept  well  propped 
up  to  facilitate  the  escape  of  discharges,  which  must  be  prevented 
from  collecting  by  frequent  syringing,  or,  what  is  better,  by  the  patient 
himself  often  rinsing  and  gargling  his  mouth  and  wound  with  some 
antiseptic  solution.  None  of  these  are  more  readily  used  than  the  old- 
fashioned  potassium-permanganate  lotion,  and  the  wound  should  be 
occasionally  brushed  over  with  iodoform  in  ether. 

In  those  cases,  rare  nowadays,  where  the  growth  is  of  great  size, 
owing  to  the  operation  being  deferred,  the  mouth  may  remain  open 
for  some  days  after,  but  the  power  over  the  muscles  which  raise  the 
lower  jaw  is  gradually  regained.   The  lost  sensation  is  usually  restored, 


276  OPERATIONS    ON    THE    HEAD    AND    NECK. 

and  the  resulting  deformity  is  often  very  slight  *  Later  on,  Avhen 
the  parts  are  soundly  healed,  the  skill  of  a  dentist  is  called  in  to  fit  on 
a  tooth-plate,t  and  obturator  if  needful. 

Partial   Extirpation  of  the  Upper  Jaw.— Operations  for 

removal  of  an  epulis  with  the  alveolar  bordur  have  been  described  at 
p.  268,  and  one  for  opening  up  and  exploring  the  antrum  is  given  at 
p.  292. 

If  the  surgeon  find  that  the  lower  part  only  of  the  upper  jaw  need 
be  removed,  abundant  room  will  be  given  by  dividing  the  upper  lip 
in  the  middle  line,  prolonging  this  round  the  columella  into  the  nostril 
on  the  diseased  side.  By  detaching  the  nose  and  dissecting  up  the  flap 
of  cheek  the  facial  surface  of  the  jaw  can  be  well  exposed. 

Again,  if,  after  exposing  the  whole  jaw  by  Sir  W.  Fergusson's  inci- 
sion, the  surgeon  finds  that  the  orbital  plate  can  be  sjDared,  a  horizontal 
saw-cut  is  made  just  below  the  infra-orbital  foramen  and  the  bone  cut 
through  with  a  chisel  and  a  few  taps  of  a  mallet.;}: 

When  the  orbital  and  nasal  parts  of  the  upper  jaw  are  involved  and 
the  lower  alveolar  portions  are  sound,  these  latter  may  be  thus  pre- 
served. A  cheek  flap  being  reflected  by  an  incision  through  the  lip 
and  upwards  to  the  inner  canthus  along  the  nose,  the  nasal  and  malar 
processes  ard  divided  while  the  eye  is  duly  protected.  A  horizontal 
saw-cut  is  then  made  above  the  alveolar  process,  outwards  from  the 
nose,  and  another  carried  upwards  from  the  outer  end  of  this,  to  join 
the  incision  through  the  malar  process,  being  made  either  with  the 
saw  or  chisel.  The  piece  of  bone  thus  mapped  out  is  loosened  with  a 
chisel  or  elevator,  and  either  prised  out  with  the  latter  instrument,  or 
wrenched  downwards  and  outwards  with  the  lion-forceps. 

Several  other  operations  involving  partial  removal  of  the  upper  jaw 
are  given  under  the  treatment  of  naso-pharAnigeal  polypus,  p.  287. 

Difficulties  and  Dangers  during  the  Operation. — These  have 
been  already  alluded  to :  the  chief  are — 

1.  Shock. 

2.  Haemorrhage. 

*  No  skin  is,  of  course,  removecl,  even  if  it  appears  to  be  very  redundant;  it  rarely 
sloughs,  save  when  the  stretching  has  been  extreme,  or  when  it  lias  been  needful  to 
apply  the  cautery  to  the  flap.  When  the  growth  has  invaded  tlie  skin  over  it,  a  hideous 
fistula  is  left,  which  must  be  closed  later  on,  if  tiie  patient  survives,  which  he  seldom 
does  in  these  cases. 

t  Mr.  Butcher  {loc.  supra  cit.,  p.  270)  in  one  case  preserved  the  last  molar  tooth  and 
part  of  the  tuberosity  as  a  fixed  point  for  a  tooth-plate,  intending  to  have  removed 
this  if  the  disease  recurred  in  it  subsequently. 

X  The  orbital  plate  should  always  be  left  if  possible.  As  Mr.  Butlin  (loc.  supra  cit., 
p.  134)  points  out,  when  the  floor  of  the  orbit  has  been  removed  there  often  results  not 
only  serious  disfigurement,  but  much  ojdema  of  the  lower  lid,  and  an  unhealthy  con- 
dition of  the  eye  itself,  which  may  be  destroyed. 


REMOVAL    OF    UPPER   JAW.  277 

3.  Breaking  down  of  the  bone  in  the  lion-forceps. 

4.  Outlying  pieces  of  growth  either  in  the  pterj'goid  or  other  fossae, 
or  in  the  temporal  region,  or  far  back  in  the  roof  of  the  nose. 

Possible  Causes  of  Failure. 

1.  Prolonged  shock.  Inability  to  rally.  Besides  the  usual  applica- 
tion of  warmth  and  injections  of  ether  and  brandy,  feeding  by  nutri- 
ent enemata  or  by  a  tube  passed  by  the  mouth  or  by  the  opposite 
nostril  should  be  early  resorted  to,  especially  in  the  case  of  elderly 
patients,  or  in  those  much  let  down. 

2.  Secondary  hemorrhage.  If  this  is  severe,  resisting  the  use  of  ice, 
etc.,  the  wound  must  be  opened  up,  and  if  no  definite  bleeding  point 
be  found,  firm  jilugging  must  be  resorted  to,  either  with  carbolized 
sponges  dusted  with  iodoform  and  tannic  acid,  or  strijDs  of  aseptic 
gauze  wrung  out  of  turpentine.  These  steps,  and  pressure  on  the 
common  carotid,  failing  to  arrest  the  hsemorrhage,  ligature  of  this 
vessel  or  of  the  external  carotid  must  be  employed. 

3.  Cellulitis  and  erysipelas.  These  grave  complications  are  likely 
to  set  in  when  the  patient  is  aged  or  much  broken  down  in  health, 
with  impaired  viscera,  or  when,  owing  to  extensive  removal  of  bone — 
e.g.,  having  to  saw  through  the  zygoma  and  loosen  the  outer  wall  of  the 
orbit,  the  surgeon  opens  up  deep  planes  of  cellular  tissue,  which  cannot, 
from  the  surroundings,  be  kept  aseptic,  most  troublesome  burrowing 
in  the  neck  probably  following.  To  cut  cellulitis  short,  free  scarifica- 
tion with  small  incisions  should  be  made  use  of  early  so  as  to  unload 
the  parts,  and  abscesses  should  be  opened  at  once. 

4.  Lung  trouble.  Broncho-pneumonia  from  inhaling  septic  matter 
is  here,  as  after  removal  of  the  tongue,  a  decided  risk.  In  this  case, 
also,  the  treatment  is  mainly  preventive,  by  using  every  endeavor  to 
keep  the  wound  sweet,  by  the  means  already  given,  p.  275. 

5.  Inflammation  of  the  l)rain  or  its  membranes. 

6.  Recurrence. 

Mr.  Butlin*  has  lately  shown  that  the  total  mortality  after  removal 
of  the  upjjer  jaw  is  nearly  30  per  cent. — a  very  large  mortality,  equal 
to  that  of  amputation  of  the  thigh  in  the  upper  half  (for  disease),  or 
perhaps  exceeding  it.  He  goes  on  to  remark  that,  if  we  are  to  reduce 
this  mortality,  "  we  must  adopt  two  courses  in  the  after-treatment,  first, 
such  means  as  will  render  the  wounds  aseptic ;  second,  regular  and 
sufficient  administration  of  food." 

\\"\ih  regard  to  the  recurrence,  Mr.  Butlin  considers  the  prospect  as 
very  gloomy,  only  four  cases  out  of  sixty-four  (in  which  the  result  is 
recorded)  being  able  to  be  considered  successful — i.e.,  having  remained 
cured  for  three  years. 

*  Oper.  Surg,  of  Mai.  Dis.,  p.  130. 


278 


OPERATIONS    OX    THE    HEAD    AND    NECK. 


OPERATIONS  FOR  NASO-PHARYNGEAL  POLYPUS 

(Figs.  59,  60,  61). 

Attachments  and  Relations. — The  surgeon  should  consider 
these  carefully  before  deciding  wiiat  operation  he  will  adopt  for  one 
of  these  most  dangerous  growths. 

These  will  vary  according  to  the  duration  of  the  polypus.  The  pri- 
mary attachments  of  the  growth  start  much  more  frequently  from  the 
base  of  the  skull,  arising  in  the  thick  periosteum  covered  by  mucous 
membrane  which  covers  in  the  roof  of  the  nose  and  top  of  the  pharynx, 
especially  the  adjacent  parts  of  the  basi-sphenoid  and  Ijasi-occipital. 
Less  frequently  they  may  arise  in  the  pterygoid  fossa  and  adjacent 

Fig.  59.* 


Naso-pharyiiReal  polypus  springing  from  the  base  of  the  slcull.    In  the  sphenoidal  sinus 
is  seen  a  smaller  polypus.    (MasstJ.) 

plates,  or  from  around  the  posterior  nares.  Dr.  Sands  f  points  out 
that  the  region  in  which  a  naso-pharyngeal  polypus  can  originate  is 
one  of  narrow  limits,  corresponding  with  the  margins  of  the  posterior 
nares  and  the  summit  of  the  pharynx.     It  is  thus  one  that  can  be 


*  This  wood-cut  is  taken  from  one  of  Dr.  Robin  Mass^'s  figures :  These  des  Polypes 
nam-pharyncjiens.     Paris,  1864. 

t  " On  Naso-Pharyngeal  Polypi":  Dr.  Brown-S^quard's  Arch,  of  Sci.  and  Praet. 
Med.,  No.  6.  According  to  Dr.  Sands,  these  polypi  may  also  spring  from  the  apex  of 
the  petrous  bone  and  the  great  wing  of  the  sphenoid. 


NASO-PHARYXGEAL    POLYPUS.  279 

satisfactorily  explored  with  the  finger,  and  by  this  means  a  polypus 
should  be  detected  in  its  early  stage  and  removed  safely  while  yet 
small. 

Wliile  the  above  are  the  most  frequent  primary  attachments  of  the 
growths,  it  should  always  be  remembered  that  when  one  of  these  polypi 
has  existed  for  some  time,  when  they  are  sloughy,  when  previous 
attemi)ts  have  been  made  to  remove  them — under  these  conditions 
the  growth  is  very  likely  to  have  taken  on  secondary  attachments.  A 
common  instance  of  these  is  seen  when  a  growth  springing  from  the 
base  of  the  skull  forms  adhesions  to  the  pterygoid  fossa?. 

If  secondary  attachments  are  made  out  to  exist,  the  next  question 
will  be,  How  far  are  these  intimate  and  close?  How  far  is  the  growth 
not  only  in  contact  with,  but  how  far  has  it  actually  absorbed  bones, 
such  as  those  of  the  nose  ?  How  far  has  it  got  into  the  antrum  and  thus 
come  to  resemble  closely  a  growth  of  the  upper  jaw?  It  is  obvious 
that  if  the  growth  is  mainly  limited  to  the  nose,  if  tlie  bones  of  this 
cavity  are  chiefly  affected,  it  is  through  the  nose  that  the  polypus 
should  be  attacked.  Again,  swelling  of  the  cheek,  with  i>rotrusion  of 
the  eye,  will  point  to  an  operation,  osteoplastic  or  otherwise,  on  the 
upper  jaw.  In  the  same  way  extension  of  the  growth  into  the  zygo- 
matic and  temporal  fossa?  will  render  the  prognosis  unfavorable. 
Finally,  any  symptoms  pointing  to  softening  of  the  base  of  the  skull 
and  implication  of  the  membranes — e.g.,  headache,  tendency  to  coma, 
convulsions,  with  evidence  of  pyrexia,  will  be  conclusive  against  any 
operation,  even  when  most  carefully  performed. 

Methods  of  Removal.— Amongst  these  are— 

(i.)  Avulsion. — In  a  few  rare  cases  where  the  growth  is  small, 
where  the  pedicle  is  distinct  and  narrow,  and  where  it  rises  from  a 
point  within  reach,  it  may  be  torn  away  with  suitably  curved  forceps 
introduced  either  by  the  nose  or  by  the  mouth,  aided  in  either  case 
by  a  finger  passed  behind  the  soft  palate. 

This  method  is  only  suitable  to  the  above  cases,  and  in  none  is 
without  danger.  Mr.  Cooper  Forster's  interesting  case*  is  a  striking 
instance  of  this.  Attempts  having  failed  to  remove  the  polypus  with 
a  wire  loop,  Mr.  Forster  introduced  a  pair  of  blunt-pointed  strong 
forceps,  and  twisted  off  several  large  pieces,  enough  to  fill  the  palm  of 
the  hand.  These  were  very  adherent,  and  required  a  great  deal  of 
force  to  detach  them.  There  was  much  hemorrhage.  Severe  headache 
quickly  followed,  then  aphasia,  restlessness,  convulsions,  and  death  on 
the  twelfth  day.  General  arachnitis  was  found,  with  sloughy  softening 
of  the  brain,  about  Broca's  convolutions.  The  growth  occupied  the 
left  side,  filling  the  space  between  the  greater  and  lesser  wings  of  the 

*  Clin.  Soc.  Trans.,  vol.  iv.  p.  159. 


'280  OPERATIONS    ON    THE    HEAD    AND    NECK. 

sphenoid,  the  orbital  plate  of  the  frontal,  and  the  cribriform  plate  of 
the  ethmoid.*  From  the  nasal  fossa^  it  had  extended  ]>y  the  sphenoidal 
fissure  into  tlie  back  of  the  orbit,  but  without  damaging  the  optic  nerve. 
The  cril)riform  plate  of  the  ethmoid  was  broken,  there  being  a  small 
opening  at  its  back  part  from  which  a  fracture  extended  forwards.  It 
seemed  beyond  doubt  that  this  fracture  had  been  effected  wliile  the 
growth  was  being  torn  away. 

The  serious  ha3morrliage,t  and  the  probal)le  incompleteness  of  the 
operation,  are  also  strongly  against  making  use  of  avulsion. 

It  is  only  right  to  state,  while  the  subject  of  avulsion  is  under  con- 
sideration, that  Prof.  Syme  was  strongly  m  favor  of  this  method  for 
naso-pharyngeal  polypi.  In  three  cases  which  he  has  briefly  recorded  X 
he  employed  the  ordinary  forceps  used  for  mucous  polypi,  introduced 
through  the  nostril,  assisting  their  action  by  the  fore  and  middle  fingers 
of  the  left  hand  introduced  behind  the  soft  palate.  He  describes  the 
bleeding  as  being  profuse,  in  one  case  "  fearful."  The  after-result  of 
only  one  case  is  given,  this  being  known  to  be  successful  for  some 
years  after  the  operation. 

The  patient  liere  had  been  under  the  care  of  Sir  B.  Brodie,  Mr. 
Travers,  Mr.  B.  Cooper,  and  Mr.  C.  Hawkins,  who  all  agreed  as  to  the 
impropriety  of  attempting  any  operation.  The  size  of  the  tumor  is 
not  given.  It  is  clear  that  Prof.  Syme's  method  could  only  be  success- 
fully adopted  in  cases  in  which  there  was  a  distinct  pedicle,  in  which 
the  growth  was  one  of  moderate  size,  and  free  from  secondary  adhe- 
sion, springing  either  from  the  base  of  the  skull  or  the  posterior  nares, 
and  invading  the  naso-pliarynx  only. 

While  it  is  only  right  that  these  cases  should  be  remembered,  it  is 
much  to  be  wished  that  the  after-histories  of  two  of  them  had  been 
more  fully  given. 

(ii.)  Ligature. — This  again  is  only  suitable  to  very  few  cases — e.g., 
where  the  pedicle  is  distinct  and  fairly  thin,  and  Avhere  the  growth 
has  contracted  no  adhesion.  In  addition  to  the  probability  of  return 
in  the  pedicle,  the  fcetor  which  accom]3anies  the  sloughing  process  is 


*  It  is  notewortliy  that  though  tliis  large  growth  (Mr  Forster  describes  it  as  "'an 
enormous  mass  around  wliich  it  was  impossible  I  could  get  the  wire"]  thus  exten- 
sively implicated  the  base  of  the  skull,  it  only  appeared  externally  as  a  firm,  fleshy 
polvpus,  filling  up  a  large  part  of  the  left  nostril,  but  apparently  not  pressing  much 
upon  the  right  one.  There  was  no  dilatation  of  any  part  of  the  face,  no  fulness  of  the 
palate,  nor  any  projection  in  the  throat. 

f  According  to  Dr.  Sands,  Diipuytren  lost  a  case  from  ha?morrhage  after  an  attempt 
to  remove  a  polypus  by  forceps,  in  which  he  succeeded  in  removing  only  a  few  frag- 
ments. If  this  method  is  ever  made  use  of,  it  might  be  wise  to  first  perform  laryn- 
gotomy,  and  ping  the  fauces  with  a  sponge. 

X   Observ.  in  Clin.  Sart/.,  p.  130  et  seq. 


XASO-PHARYNGEAL    POLYPUS.  281 

a  most  serious  drawback*  If  the  ligature  were  to  be  used  at  all, 
every  attempt  should  be  made  to  get  rid  of  the  growth  at  the  time  by 
attaching  tiie  ligature  after  it  is  placed  round  the  pedicle  to  a  suitable 
ecraseur,  and  so  removing  it.  Care  must  be  taken  in  such  cases  to 
prevent  the  growth,  when  the  pedicle  is  divided,  falling  upon  the 
larynx. 

(iii.)  Galvanic  Loop. — In  the  very  few  cases  where  ligature  can 
be  tried,  this  modification  would  probably  be  the  best.  But  even  here 
the  pedicle  would  be  left,  unless  the  surgeon  possesses  special  instru- 
ments, such  as  the  post-nasal  galvano-cautery,  and  experience  in 
using  it. 

The  following  case,  which  was  under  the  care  of  two  Italian  sur- 
geons, is  thus  reported  in  the  Syd.  ISoc.  Blen.  Retr.,  1871,  1872,  p.  236. 
Unfortunately,  as  is  so  often  the  case,  the  result  is  not  given. 

The  tumor  was  round,  very  hard,  smooth,  and  attached  by  a  broad 
pedicle  to  the  pharynx,  the  upper  part  of  which  it  occupied.  A  Bel- 
loc's  sound,  introduced  through  the  nostril,  was  passed  between  the 
tumor  and  the  uvula  ;  one  end  of  a  silk  thread  was,  by  means  of  the 
sound,  carried  into  the  nose,  and  the  two  ends  of  a  p'atinum  wire, 
about  2  feet  long  and  -^^  inch  thick,  were  fastened  to  the  other  end. 
The  silk  thread  was  drawn  through  the  nose,  and  by  manipulating 
the  wire  loop  in  the  mouth,  it  was  placed  as  high  as  possible  on  the 
pedicle  of  the  tumor.  The  ends  of  the  wire  were  then  placed  in  con- 
nection with  the  battery ;  the  circuit  kept  closed  for  twenty  seconds, 
traction  at  the  same  time  being  made  on  the  wire.  The  current  was 
now  interrupted,  and  the  loop,  which  had  cut  into  the  tumor,  was 
placed  more  accurately  on  the  pedicle.  The  circuit  was  again  com- 
pleted, and  the  tumor  was  cut  through  at  its  base,  and  removed 
through  the  mouth  by  the  fingers.  It  measured  nearly  2  inches  longi- 
tudinally, and  Ih  transversely.  The  patient  felt  no  sensation  of  heat 
during  the  operation ;  it  was  not  followed  by  pain,  hasmorrhage,  or 
any  discharge. 

(iv.)  Electrolysis. — This  method  is  both  most  tedious  and  uncer- 
tain. It  can  only  be  used  as  an  auxiliary.  Thus,  Dr.  Sands  suggests 
that  after  removal  of  the  growth  its  pedicle  might  be  successfully 
treated  by  electrolysis. 

Where  patients  are  weakened  by  repeated  bleeding,  the  haemorrhage 
may  be  arrested  by  electrolysis,  and  the  growth  sufficienth'  reduced  in 
size  to  allow  of  its  being  removed  through  the  natural  passages.  The 
following  casef  was  under  the  care  of  M.  Ciniselli : 

*  Dr.  Sands  quotes  otiier  causes  of  death  as  not  infrequent — viz.,  suffociition  from' 
detaclinient  of  the  growth,  pyppmia,  and  oedema  of  the  larynx. 

t  Syd.  Soc.  Bien.  Retr.,  1873-1874,  p.  291.  M.  Ciuiselli's  wide  experience  with  the 
galvano-cautery  is  well  known. 


282  OPERATIONS    OX    THE    HEAD    AND    NECK. 

The  entire  wall  of  the  pharynx  was  found  to  be  occupied  by  a  fleshy 
SAvelling  which  comi^letel}^  blocked  up  the  left  aperture  of  the  nares 
and  pressed  the  epiglottis  against  the  base  of  the  tongue.  The  start- 
ing-point of  the  tumor  could  not  be  discovered.  The  patient  being 
extremely  emaciated  and  aniemic,  any  operation  involving  loss  of 
blood  was  impossible,  and  therefore  Ciniselli  determined  to  apply  the 
galvanic  cauter3^  On  Nov.  20,  1869,  he  commenced  with  a  small  bat- 
terv  of  eight  elements.  The  reophores,  of  steel,  were  a})Out  4}  inches 
long,  and  were  covered  with  india-rubber  to  about  1  inch  from  the 
ends.  The  needle  of  the  negative  pole  was  introduced  through  the 
left  nostril  into  the  polypus,  the  other  through  the  mouth  into  the 
right  side  of  the  swelling,  and  the  current  was  passed  through  the 
tumor  for  fourteen  minutes.  On  Nov.  29,  there  commenced  a  dis- 
charge from  the  left  nostril  of  a  brownish-yellow  fluid  containing 
shreds  of  destroyed  connective  tissue.  On  Dec.  8,  respiration  and  de- 
glutition were  more  easy.  After  twenty  sittings,  the  tumor  decreased 
so  much  that  in  Oct.,  1871,  there  was  only  a  slight  indurated  elevation 
in  the  posterior  inferior  wall  of  the  pliarynx. 

(v.)  Excision  by  an  Operation  involving  Removal  of  Bone, 
Ostsoplastic  or  otherwise. — These  may  be  divided  as  follows : 

A.  Those  through  which  the  attack  is  made  by  the  mouth. 

B.  Those  by  which  the  attack  is  made  through  the  nose. 

C.  Those  by  which  the  attack  is  made  by  removing  the  upper  jaw, 
partially  or  completel}^  or  by  resecting  this  bone  osteo-plastically. 

A.  Operation  for  Nam-pharyngenl  Polypus  through  the  Mouth  (Fig.  61). 
— This  operation  was  strongly  advocated  by  M.  Nelaton.*  It  consists 
in  slitting  the  uvula  and  soft  palate  exactly  in  the  middle  line  from 
before  backwards,  then  prolonging  this  incision  along  the  centre  of  the 
posterior  half  of  the  hard  palate,  going  here  down  to  the  bone ;  from 
the  end  of  this  incision  two  others  are  made  slightly  obliquely  out- 
wards towards  the  teeth,  also  going  down  to  the  bone.  The  flaps, 
together  with  the  periosteum,  are  then  detached,  so  as  to  form  nearly 
rectangular  flaps.f  Two  large  holes  are  then  drilled  through  the 
hard  palate,  each  well  to  one  side  of  the  middle  line,  the  intervening 
bone  is  cut  away  l)y  placing  the  ends  of  cutting-pliers  in  each  of  these 
holes,  and,  by  making  lateral  cuts  back  to  the  free  border  of  the  hard 
palate,  a  rectangular  portion  of  the  posterior  half  of  the  bony  vault  is 
removed.  The  mucous  membrane  and  the  periosteum  on  the  upper 
surface  of  the  bone,  which  will  now  be  found  detached,  are  divided, 
.and,  if  needful  to  get  more  room,  more  or  less  of  the  vomer  is  cut 

*  Masse,  Inc.  supra  cit.,  p.  53. 

t  This  detachment  is,  as  is  well  known  in  stapliyiorapliy,  difficult  posteriorly  at  the 
junction  of  the  palates,  and  woald  best  be  effected  by  curved  scissors. 


XASO-PHARYXGEAI.    POLYPUS.  283 

away.  Room  being  thus  obtained,  the  polypus  is  removed  and  its 
pedicle  dealt  with.  If  all  the  growth  is  got  away  satisfactorily,  the 
palate  tiaps  are  united  in  the  ordinary  way  :  if  further  treatment  is 
required,  staphyloraphy  must  be  performed  later. 

The  advantages  of  this  operation,  when  contrasted  with  removal  of 
the  upper  jaw,  are  at  first  sight  considerable. 

(1)  There  is  no  deformity  left  on  the  face;  (2)  the  parts  cut  through 
are  less  important;  (3)  mastication  is  not  interfered  with  by  removal 
of  the  teeth  ;  (4)  the  operation  is  less  difficult ;  (5)  the  haemorrhage  is 
less,^  no  large  vessels  being  cut  through  ;  (6)  the  growth  is  attacked 
directly  ;  (7)  through  the  gap  thus  left  the  surgeon  can  again  attack 
the  growth,  within  a  few  days,  if  he  has  been  unable  to  complete  the 
operation,  or  later  on,  if  recurrence  takes  place ;  (8)  the  gap  can 
easily  be  dealt  with  later  on  by  staphyloraph}",  or  by  wearing  an 
obturator. 

I  am  afraid  that  on  closer  examination  the  above  will  not  bear  the 
onh'  true  test.  The  first  three  are  no  doubt  of  great  value  if  the 
growth  can  be  entirely  dealt  with  by  this  method  ;  otherwise,  consid- 
ering the  malignancy  of  these  growths,  the  inveterate  way  in  which  they 
recur,  if  incompletely  dealt  with,  neither  surgeon  nor  patient  would 
be  wise  in  running  great  risks  for  the  sake  of  what  one  may  call  rather 
aesthetic  advantages.!  There  is  no  doubt  that,  in  a  few  cases,  to  be 
mentioned  a  little  later,  where  the  polypus  is  of  moderate  size,  dis- 
tinctly pedunculated,  and  attached  low  down,  e.g.,Sihout  the  posterior 
nares,  or  well  forward  on  the  base  of  the  skull,  the  operation  will  be 
easier,  the  haemorrhage  will  be  less,  and  the  growth  will  be  more 
directly  attacked.  The  advantage  of  a  future  staphyloraphy  is,  like 
those  given  first,  not  of  sufficient  value  to  recommend  this  operation 
if  it  is  wanting  in  more  important  points. 

Turning  to  the  cases  themselves,  Dr.  Robin  Masse  has  collected  X 
twenty-six  treated  by  this  method,  twelve   having   been  under   the 


*  Tliis  is  very  doubtful.  Dr.  Sands  (loc.  supra  cii),  in  removing  a  polypus  by  this 
method,  had  surrounded,  without  difficulty,  tlie  pedicle  with  an  ecraseur-chain.  Tliis 
breaking,  the  pedicle,  wliich  was  stout  and  firm,  was  divided  witii  scissors  as  close  to 
the  skull  as  possible.  Copious  hiemorrhage  foHowed,  and  much  time  was  consumed  in 
unsuccessful  attempts  to  secure  a  large  artery  which  had  retracted  tuthe  deepest  part 
of  the  wound,  and  which  was  inaccessil)le  to  the  ligature.  The  bleeding  finally  ceased, 
in  consequence  of  tlie  prostration  of  the  patient,  who  had  several  alarming  attacks  of 
syncope.  The  growth  recurring,  it  was  removed  by  the  method  of  Maisonneuve. 
Though  it  was  not  thought  prudent  to  attempt  a  small  prolongation  which  ran  into  the 
sphenoidal  sinus,  no  recurrence  had  apparently  taken  place  nine  months  later. 

t  1  may  here  draw  attention  to  the  great  fretjuency  of  these  polypi  in  males,  in 
whom  the  growth  of  hair  will  largely  conceal  the  facial  deformity  con.sequent  on  oper- 
ations through  the  upper  jaw. 

X   These,  loc.  supra  cit. 


284  OPERATIONS    OX    THE    HEAD    AND    NECK. 

hands  of  M.  Nelaton  himself.  Of  these  twenty-six,  thirteen  are  said 
to  have  been  successful,  but  it  is  not  stated  for  how  long  they  were 
followed  up.  In  one  case,  in  which  the  after-history  is  given,  a  small 
recurrence  took  place  two  years  later  from  the  pedicle,  and  was 
destroyed.  While  suited  to  the  cases  mentioned  above,  it  could 
scarcely  be  made -use  of  successfully  in  large  polypi,  in  the  case  of 
those  with  secondary  attachments  or  large  sessile  bases,  or  in  the  case 
of  thqse  which  have  extended  into  the  pterygoid  fossa3,  or,  in  fact, 
beyond  the  naso-pharynx.  Save  by  French  surgeons,  it  does  not  ap- 
pear, to  have  been  .much  used,  from  the  belief  that  the  space  given  is 
too  limited.* 

Dr.  tSands  points  outf  that,  in  the  majority  of  the  cases  in  which 

*,  Quite  recently  Mr.  Stonliam  (Lancet,  January  7,  1888)  has  recorded  a  case  of  naso- 
pharyngeal ])olypu.s,  in  wliicli  "  the  soft  palate  was  divided  in  the  middle  line,  and  an 
attempt  made  to  remove  the  growth  through  the  month  ;  but  this  plan  failing  to  give 
sufficient  room,  the  nasal  cavity  was  opened  up,"  and  the  growth  thus  successfully 
removed. 

I  have  no  experience  of  this  operation  myself,  but  I  should  expect  that  the  bleeding, 
thougli  from  smallel'  vessels,  might,  owing  to  the  confined  space,  and  thus  a  more  pro- 
longed operation,  almost  equal  that  met  with  in  operative  attacks  through  the  jaw, 
while  the  vicinity  of  the  larynx  makes  any  hicmorriiage  here  more  embarrassing.' 
■Again,  in  those  patients  with  narrow,  highly  arclied  palates,  tiiis  operation  would  be 
accompanied  with  very  great  difficulty. 

M.  Guerin  {Gaz.  des  Hop.,  1865,  p.  575;  Syd.  Soc.  Bien.  Retr.,  1865-00,  p.  241)  re- 
lated a  case  of  polypus  whicli  he  removed  by  a  modilication  of  tiie  above  method. 
Tlie  polypus  was  of  enormous  size;  the  boy  (aged  seventeen^  could  only  breatiie  with 
liis  moutli  half  open,  and  the  velum  palati  was  so  displaced  as  to  be  turned  down 
towards  the  br^se  of  the  skull.  The  attachment  of  the  tumor  appeared  to  be  somewhere 
near  the  posterior  nares.  The  velum  palati  having  been  divided,  a  polypus  as  large  as 
a  hen's  egg  was  di-awn  into  the  moutli,  and  its  pedicle  severed  without  difficulty  and 
with  little  bleeding,  though  enough  to  be  dangerous  in  the  patient's  condition,  which 
was  one  of  exhaustion  from  previous  haemorrhage.  On  examination  it  was  found  that 
the  bulk  of  the  disease  was  left  behind  in  the  form  of  a  large  mass,  round  wiiich  the 
finger  could  not  be  passed,  and  which  appeared  incarcerated  in  some  way  that  could 
not  be  made  out.  The  finger  was  carried  down  behind  the  mass  from  the  mouth,  and 
a  rasp  was  pushed  through  the  nostril  on  to  the  base  of  the  skull,  and  thus  the  mass  was 
detached  from  the  cranium,  together  with  what  remained  of  the  pedicle  of  the  former 
tumor,  which  was  still  bleeding.  A  large  bony  cavity  was  thus  exposed,  which  seemed 
to  be  the  dilated  sphenoidal  sinus.  The  pedicle  was  now  easily  felt  and  detached, 
partly  with  one  blade  of  a  pair  of  scissors,  partly  with  a  rasp.  The  bones  were  then 
felt,  rough,  and  devoid  of  periosteum  Tliere  was  little  bleeding.  Three  days  later 
the  galvano-cautery  was  applied  to  some  inequalities  felt  near  the  pedicle  of  the 
polypus,  under  the  fear  that  this  might  be  a  new  growth.  M.  Guerin  has  found  that, 
in  the  case  of  large  polypi,  the  pharynx  being  accustomed  to  the  presence  of  a  foreign 
body,  the  introduction  of  the  finger  is  easier,  and  gives  less  annoyance  than  in  healtiiy 
persons. 

f  Loc.  supra  cit.,  p.  514, 


NASO-PHARYNGEAT^    POLYPUS.  285 

surgeons  have  operated  through  the  palate,  they  have  had  to  leave  the 
wound  open  in  order  to  remove  the  pedicle  later.  This. step  is  ])y  no 
means  as  easy  as  might  be  imagined,  and  in  m^awy  cases  me  surgeon 
has  been  driven  later  to  make  use  of  another  operation  when  the 
patient's  condition  is  less  satisfactory.  Furthermore,  the  result  of 
repeated  irritation  in  the  shape  of  attempts  at  the  destruction  of  the 
pedicle  with  caustics,  the  cauterj'',  etc.,  is  too  likely  to  take  the  form 
of  rapid  sarcomatous  growth.*  t 

B,  Operation  for  Naso-pharyngecd  Polypus  through  the  i\o.«'.— Under 
this  heading  will  l^e  included: 

1.  Rouge's  operation. 

2.  Lawrence's  operation. 

3.  Langenbeck's  operation. 

4.  Oliier's  operation. 

These  operations  through  the  nose  are  only  suited  to  cases  in  which 
the  bulk  of  the  polypus  is  nasal  rather  than  pharyngeal,  and  in  which 
its  pedicle  is  attached  to  a  point  well  within  reach,  as  around  the  pos- 
terior nares — for  cases,  in  short,  the  removal  of  which  -might  perhaj^s 
be  attempted,  by  the  use  of  forceps^,  by  the  nose,  but  in  which  addi- 
tional room  is  required.  They  may  also  be  used  in  doubtful  cases 
for  exploratory  purposes.  For  other  cases,  the  room  which  they  give, 
and  the  access  which  they  afford  to  the  tumor,  will  probably  be  found 
insufficient.  Dr.  Sands,  in  speaking  of  Langenbeck's  operation  .(the 
only  one  which  he  mentions),  says  that  he  has  found  that,  after  the 
nasal  bone  and  the  nasal  process  of  the  superior  maxilla  have  been 
removed,  the  distance  of  the  basilar  process  of  the  occipital  from  the 
anterior  opening  is  nearly  3  inches,t  and,  although  the  boundaries  of 
the  nasal  fossae  would,  in  any  given  case,  probably  be  dilated  by  the 
tumor,  the  space  thus  afforded  would  rarely  be  found  sufficient  for 
satisfactory  dealing  with  the  pedicle. 

(1)  Rouge's  operation.     This  has  already  been  described  at  p.  265. 

(2)  Lawrence's  operation.;}:  In  this,  the  back  of  the  nasal  cavity  is 
exposed  and  got  at  by  turning  up  the  nose. 

The  integuments  are  first  divided  on  each  side  of  the  nose  by  an 
incision  beginning  at  a  point  just  internal  to  the  lachrymal  sac,  and 

*  Dr.  Sands  points  out  that  the  deep  situation  of  the  growth,  and  its  position  near 
the  larynx,  render  the  use  of  caustics  both  difficult  and  dangerous. 

t  The  experience  of  other  surgeons  is  not  in  accord  with  this.  Thus  M.  Hei-gott 
{Gaz.  des  Hop.,  1867,  p  97),  in  the  case  of  a  pol.vpns  recurrent  after  treatment  by  liga- 
ture, tried  ras[)ing  the  point  of  implantation  on  the  base  of  the  skull.  He  found  that 
an  instrument  passed  through  the  anterior  nares  impinged  exactly  upon  this  point; 
the  bone  was  easily  denuded,  and  seven  months  afterwards  no  trace  of  reproduction 
was  visible. 

X  Med.  Times  and  Gaz.,  1862,  vol.  ii.  p.  491. 


286  OPERATIONS    ON    THE    HEAD    AND    NECK. 

carried  down  to  the  junction  of  the  ala  and  the  lip.  Next,  the  incision 
is  completed  by  cutting  through  the  nasal  bones  and  the  nasal  pro- 
cess of  the  superior  maxilla  with  bone-forceps.  The  septum  being 
now  divided,  the  nose  is  turned  up  and  the  posterior  part  of  the  cavity 
exposed. 

(3)  Langenbeck's  operation  through  the  nose*  (Fig.  60). 

In  this  the  polypus  is  attacked  through  the  upper  part  of  the  nose, 
by  the  following  osteoplastic  o])eration :  The  soft  parts  were  first 
divided  by  an  incision  reaching  from  the  centre  of  the  root  of  the  nose 
obliquely  downwards  and  outwards  on  one  side  of  the  nose  on  to  the 
cheek,  and  ending  at  a  point  external  to  the  ala  nasi.  The  soft  parts 
on  the  upper  lip  of  the  wound  being  raised  upwards  and  outwards,  a 
vertical  incision  was  made  upwards  through  the  nasal  bone  to  the 
nasal  spine  of  the  frontal,  and  a  second  outwards  from  the  bony  mar- 
gin of  the  anterior  nares  to  the  margin  of  the  orbit.  The  nasal  bone 
and  the  nasal  process  of  the  superior  maxilla  were  then  forcibly  dis- 
placed upwards,  together  with  their  periosteum,  being  still  connected 
with  the  frontal  bone  by  skin,  periosteum,  and  mucous  membrane. 

The  polypus,  which  is  stated  to  have  been  of  considerable  size,  was 
then  easily  removed,  the  bones  replaced,  and  the  skin  united  Avith  a 
few  points  of  suture.  The  patient  made  a  good  recovery,  a  lachrymal 
fistula  which  formed  being  closed  after  some  small  pieces  of  bone  had 
exfoliated. 

This  method  has  been  used  several  times  successfully.  The  cases 
to  which  it  appears  to  be  suited  have  already  been  indicated  (p.  285). 

(4)  Ollier's  operation  through  the  nosef  (Fig.  80). 

In  this  method  the  nose  is,  by  an  incision  somewhat  like  the  last, 
only  bilateral,  turned  downwards.  M.  Oilier  begins  his  incision  at 
the  edge  of  the  bone,  close  behind  the  ala  of  the  nose,  carries  it  up- 
w^ards  along  its  side  to  the  highest  part  of  the  depression  between  the 
eyes,  then  across,  down  to  the  corresponding  point  on  the  other  side. 
The  bone  is  sawn  through  in  the  line  of  the  incisicm,  the  necessary 
liberating  incisions  made  in  the  septum  and  the  sides,  and  the  nose 
turned  down.  The  septum  is  pressed  aside,  the  polypus  extracted,  its 
base  of  implantation  scraped,  and  the  nose  replaced. 

A  modification  which  is  sometimes  desirable  on  account  of  the  size 
of  the  polypus,  or  the  distance  of  its  imphmtation,  is  indicated  in  Fig. 
79.  The  incision  is  made  obliquely  outwards  upon  the  cheek,  and  a 
transverse  one  is  made  from  each  end  inwards  to  the  ala  of  the  nose. 
The  bone  is  divided  in  the  direction  of  the  skin  incisions — in  the  ver- 
tical one,  as  before  described ;  in  the  horizontal  one,  bv  passing  a  fine 

*  Deut.  Klinik,'iS;   Gaz.  Hebd.,  January  27,  1860. 

f  I  am  indebted  for  the  following  brief  account  of  M.  Ollier's  operation  to  Dr.  Stim- 
son's  Operative  Stirgenj,  p.  185. 


NASO  PHARYNGEAL    POLYPUS. 


287 


saw  across  the  nostrils,  through  holes  made  between  the  bone  and  car- 
tilages, and  sawing  outwards.  This  line  of  section  must  be  high 
enough  to  avoid  the  roots  of  the  teeth. 

C.  Operations  for  naso-pharyngeal  jwlypus  by  removal  of  the  upper  jaw  : 
(1)  partially ;  (2)  completely  ;  or  (3)  by  osteoplastic  operation  on  this  bone. 

(i.)  Partial  Removal  of  the  Upper  Jaw. — These  operations  are  very 
numerous;  one  or  two  will  be  given  as  specimens. 

(ii.)  Complete  Removal  of  the  Upper  Jaw. — This  has  already  been  fully 
considered,  p.  273. 

a.  Method  of  Maisonneuve*  and  Gu<kint  (Fig.  61). 

Dr.  Robin  Masse  {he.  supra  cit.,  p.  51)  states  that  the  so-called  oper- 
ation of  Maisonneuve  is  really  that  of  Guerin,  with  only  a  modification 
in  the  division  of  the  soft  parts.     The  essential  point  is  to  get  room 


Fig.  go. 


Fig.  Gl. 


Fig.  60.— Langeiibeck's  operation  through  the  nose,  and  Berard's,  through  the  upper  part  of 
the  jaws,  for  uaso-pharyugeal  polypus. 

Fig.  61. — The  dotted  lines  show  Maisonneuve's  operation,  the  two  continuous  ones  that  of  Lan- 
genbeck's  osteoplastic  operation  ou  the  jaw.  On  the  hard  palate  are  the  lines  of  Nelaton'.s  oper- 
ation.   Trephining  the  frontal  sinuses  is  indicated  above. 

for  attacking  the  polypus  by  removal  of  the  lower  part  of  the  jaw. 
This  bone  being  sufficiently  exposed  by  raising  the  soft  parts  over  it 
— and  for  this  purpose  the  method  of  Sir  W.  Fergusson  seems  superior 
to  those  given  by  the  above  French  surgeons — the  hard  and  soft  palate 
are  then  divided  in  the  middle  line,  and  the  soft  detached  transversely 
on  the  side  to  be  operated  upon.  The  hard  palate  is  next  divided  in 
the  middle  line  b}^  saAV  and  bone-forceps,  working  from  the  nose  into 
the  mouth.     By  a  transverse  section  with  a  narrow-bladed  saw  intro- 

*  Gaz.  de.'i  Hop.,  21  Aotit,  1860. 
t  Elem.  Chir.  Oper.,  1858. 


28S  OPERATIONS    OX    THE    HEAD    AND    NECK. 

duced  into  the  nose,  and  made  to  cut  horizontally  outwards,  the  facial 
aspect  of  tlie  bone  is  divided  as  far  as  the  maxillary  tuberosity.*  The 
lower  ]iart  of  the  jaw  is  then  strongly  depressed,  and  thus  detached, 
consisting;  of  the  alveolar  and  palatine  processes,  a  portion  of  the  body, 
and  a  varying  amount  of  the  pterygoid  processes  which  usually  comes 
away  with  it.     The  polypus  is  then  extirpated.t 

h.  Method  of  M.  Berard. 

In  this  the  upper,  not  the  lower,  part  of  the  jaw  is  removed,  so  as  to 
preserve  intact  the  teeth  and  alveolar  process  of  the  palate.  The  soft 
parts  being  raised  as  before,  the  bone  to  be  removed  is  marked  out  by 
the  incisions  shown  in  Pig.  60. 

(iii.)  Osteopladic  Ojierations  on  the  Upper  Jav. — In  this  the  bone  is 
cut  through  by  various  incisions,  turned  in  different  directions  on 
some  uncut  attachments,  as  on  a  hinge,  and  then  fitted  down  again 
after  the  removal  of  the  growth. 

Method  of  Prof.  Langenbeck|  (Fig.  61). — This  is  one  of  the  best 
known  of  the  above  operations.  Its  object  is  to  get  at  the  polypus, 
especially  one  in  the  pterygo-maxillary  fossa,  Avithout  interfering  with 
the  alveolar  and  palatine  processes  or  with  the  orbital  plate.  Two 
semilunar  incisions,  with  their  convexities  downwards,  are  made  across 
the  facial  aspect  of  the  upper  jaw,  the  lower  running  from  the  ala  of 
the  nose  to  the  middle  of  the  malar  bone,  the  second  starting  from  the 
nasal  process  of  the  frontal  and  passing  just  below  the  orbit  to  meet 
the  first,  where  this  ended.  If  needful,  owing  to  the  extension  of 
growths  backwards,  the  meeting  of  these  incisions  niay  be  carried  back 
along  the  zygoma.  Each  cut  is  made  down  to  the  bone,  but  the  skin 
is  not  reflected.  At  the  outer  end  of  the  lower  one  the  masseter  is 
detached  from  the  zygoma,  and  if  the  growth  has  extended  out  into 
the  zygomatic  fosste  it  will  noAv  come  into  view  on  dividing  the  buccal 
fascia.  Prof.  Langenbeck  found  at  this  stage  that  by  pressing  the 
growth  to  one  side  and  depressing  the  lower  jaw,  he  could  pass  his 
finger  through  the  pterygo-maxillary  fissure  into  the  s])heno-maxillary 
fossa,  and  so  on  through  the  spheno-palatine  foramen  into  the  nose, 
all  these  parts  being  enlarged  by  the  pressure  of  the  growth.  By 
means  of  a  narrow  straight  saw,  introduced  the  saiiie  way,  the  upper 
jaw  was  cut  through  horizontally  from  behind  forwards,  while  a  fore- 
finger passed  by  the  mouth  kept  the  tip  of  the  saw  from  striking 

*  This  section  should  pass  above  the  roots  of  the  teeth  and  well  below  the  infra- 
orbital foramen.  Accurately  speaking,  it  was  mainly  performed,  in  the  hands  of  its 
introducers,  with  bone-forceps. 

t  Dr.  Sands  appends  to  his  paper  a  photograph  of  the  patient  on  whom    he  had 
operated  by  this  method,  after  failing  to  remove  the  polypus  by  the  plan  of  M.  Nela- 
ton.     Tlie  deformity  is  very  slight,  the  malar  prominence  and  the  fulness  of  the  chee 
being  well  preserved. 

X  Deuts.  Klin.,  1861,  p.  281  ;  and  Schmidt's  Jahrb.,  vol.  cxiii.  p.  193. 


ISTASO-PHARVKGEAL    POLYPUS.  289 

against  the  septum  nasi.  The  saw  was  now  applied  along  the  upper 
incision  so  as  to  divide  the  zygoma,  the  frontal  process  of  the  malar, 
and  the  upper  jaw,  just  below  the  orbit,  up  to  the  inner  end  of  the  in- 
cision. The  portion  of  the  upper  jaw  thus  marked  out  now  only 
remained  attached,  at  its  inner  part,  to  the  nasal  bone  and  nasal  pro- 
cess of  the  frontal.  Upon  these  connections,  as  upon  a  hinge,  the 
piece  of  bone  was  slowly  raised  by  means  of  an  elevator  introduced 
under  the  malar  bone,  upwards  and  inwards,  until  the  malar  bone  was 
nearly  in  the  middle  of  the  face.  The  growth  was  now  completely 
exposed.  The  operation  took  an  hour,  and  was  attended  with  much 
hsemorrhage,  most  of  which  stopped  spontaneously.  The  wounds 
healed  well,  a  tendenc}^  of  the  bone  to  rise  being  met  by  pressure. 

At  the  present  time  any  surgeon  making  use  of  the  above  operation 
would  wire  the  bone  Avhen  fitted  down.  I  would  suggest,  too,  that 
the  incisions  through  the  bones  might,  perhaps,  be  more  easily  made 
with  an  osteotome  and  mallet,  especially  in  cases  wh^re,  the  deep 
parts  at  the  back  of  the  jaw  being  not  so  much  dilated  as  in  Prof. 
Langenbeck's  case,  it  is  difficult  to  manipulate  a  saw  and  to  cut  from 
behind  forward. 

Prof.  Langenbeck's  patient  was  a  lad  of  fifteen.  The  growth  could 
be  felt  by  tlie  finger  in  the  mouth,  filling  up  the  posterior  nares  on 
the  left  side,  passing  out  between  the  masseter  and  maxilla ;  and  on 
this  side,  too,  the  zygoma  appeared  more  prominent,  and  the  temporal 
fossa  more  full. 

This  operation  seems  well  suited  to  growths  in  the  pterygo-maxil- 
lary  fossa.  Its  drawbacks  seem  to  be  that,  (1)  if  the  upper  jaw  has  to 
be  sawn  from  behind  forwards,  this  cannot  be  done  easily  unless  the 
fossffi  at  the  back  of  the  jaw  and  the  spheno-palatine  foramen  are 
much  dilated ;  ( 2)  if  the  growth  is  mainly  limited  to  the  naso-pharynx, 
this  region  will  not  be  well  exposed  unless  the  pterygoid  process  is 
removed  as  well ;  (3)  very  disfiguring  scars  are  left. 

Other  osteoplastic  operations  have  been  described  bearing  the  names 
of  von  Bruns*  of  Tiibingen,  in  Avhich  the  whole  nose  is  turned  over 
to  one  side,  and  that  of  Roux  f  of  Toulon,  in  which  the  whole  upper 
jaw  and  malar  bone,  together  with  the  soft  parts  which  cover  them, 
are  turned  outwards  and  upwards  on  to  the  temple.  The  former  is 
said  to  have  been  performed  three  times  successfully, J  but  I  have  been 

*  Bed.  Kim.  Woch,  Nos.  12  and  13,  1872;  Syd.  Soc.  Bien.  Reir.,  1871-1872,  p.  235. 

t  Gaz.  des  Hop.,  1861,  p.  354;  Syd.  Soc.  Bien.  Eetr.,  1862,  p.  290. 

t  Tn  the  Bed.  Klin.  Wock.,  April  27,  1874  {Syd.  Soc.  Bien.  Betr.,  1873-1874),  is  the 
report  of  a  case  operated  on  by  von  Brnns's  method,  in  which,  after  raising  half  of  the 
nose,  there  was  so  raiicli  bleeding  tliat  it  was  needful  to  plug  tlie  part  and  to  defer  the 
operation  for  two  days.  Tiie  operation  was  tlien  completed,  and  liq.  ferri  percli. 
applied  to  the  stump  of  the  pedicle.     There  was  no  recurrence  six  months  later. 

19 


290  OPERATIONS    ON    THE    HEAD    AND    NECK. 

unable  to  learn  how  far  the  success  was  really  permanent.  M.  Roux's 
operation  has  not,  I  believe,  been  performed  on  the  living  subject,  the 
patient  for  whom  it  was  planned  refusing  to  undergo  an  operation. 
M.  Huguier,  *  having  raised  the  soft  parts  off  the  facial  aspect  of  the 
upper  jaw,  divided  this  bone  horizontally  from  the  maxillary  tuber- 
osity to  the  anterior  nares  ;  an  incisor  tooth  was  then  drawn,  and  the 
hard  palate  notched  with  the  saw  on  the  left  side  of  the  septum.  The 
base  of  the  pterygoid  process  being  cut  through,  the  lower  part  of  the 
jaw  (detached  from  the  other  bones  except  towards  the  middle  line, 
where  it  is  still  held  by  the  soft  parts  covering  the  two  surfaces  of  the 
hard  palate  and  by  part  of  the  alveolar  process)  is  dislocated  down- 
Avards  and  to  the  opposite  side,  within  the  mouth,  by  means  of  a  chisel 
used  as  a  lever  and  by  means  of  a  ligature  passed  through  the  nose 
and  out  of  the  mouth  by  a  Belloc's  sound.  The  polypus  was  well 
seen  adhering  extensively  to  the  basilar  process,  back  of  the  pharynx, 
and  base  of, the  left  pterygoid  process.  Up  to  this  stage  there  had 
been  little  bleeding,  but  frightful  hcemorrhage  took  place  on  removing 
the  polypus  with  gouge  and  scissors.  The  patient  made  a  good 
recovery,  being  able  to  masticate,  swallow,  and  speak  without  the 
least  difficulty. 

Dr.  Chevers,t  of  Boston,  performed  the  following  osteoplastic  opera- 
tion on  both  the  upper  jaws  at  the  same  time  :  Having  dissected  up 
flaps  on  either  side  by  incisions  such  as  Fergusson's,  so  as  to  expose 
the  bones  as  far  as  the  malar  prominences,  the  facial  surfaces  of  the 
bones  were  divided  by  horizontal  incisions  resembling  those  of  Mai- 
Bonneuve  from  the  middle  meatus  outwards  to  a  point  below  the 
zygomata.  Tlie  septum  and  the  vomer  being  divided  with  strong 
scissors,  the  lower  parts  of  the  jaws  were  depressed,  moving  on  their 
attachments  to  the  pterygoid  processes  as  upon  a  hinge.  The  growth, 
resembling  a  large  lemon  attached  to  the  ethmoid  and  body  of  the 
sphenoid,  was  then  removed  partly  with  the  finger  and  partly  with 
the  scissors  and  gouge.  The  depressed  bones  were  wired  in  position. 
The  patient,  who  seems  never  to  have  really  rallied,  died  on  the  fifth 
day. 

The  Choice  of  an  Operation  for  Removal  of  Naso-pha- 
ryngeal  Polypus. — The  relative  values  of  several  of  the  above 
operations  have  already  been  briefly  given.  The  surgeon  will  have 
to  weigh  duly  the  following :  On  the  one  hand,  the  desire  to  get  the 
growth  away  with  as  little  mutilation  and  danger  to  his  patient  as 
possible,  and,  on  the  other,  the  fact  that  these  growths  are  most  cer- 
tainly malignant  in  nature,  and  that  any  partial  operation,  while 

*  Gaz.  des  Hdp.,  1861,  p.  337. 

f  Med.  and  Surg.  Repn.  of  the  Boston  City  Hospital,  1870. 


NASO-PHARYXGEAL    POLYPUS.  291 

probably  as  difficult  and  as  bloody  as  one  on  a  larger  scale,  will,  if 
incomplete,  be  certain  to  lead  to  increased  growth  in  the  tumor  by  the 
irritation  which  it  causes,  while  for  naso-pharyngeal  polypi  which 
come  early  under  treatment,  in  which  the  growth  is  of  moderate  size 
{i.e.,  not  larger  than  a  hen's  egg),  with  a  pedicle  situated  well  forward 
in  the  roof  of  the  pharynx  or  within  easy  reach  from  the  posterior 
nares,  especially  polypi  which  can  be  made  out  to  occupy  cliiefly  the 
region  of  the  nose,  such  operations  as  those  of  Lawrence,  Nelaton,  or 
the  first  one  of  Langenbeck's  may  be  made  use  of. 

In  cases  of  greater  difficulty,  from  the  longer  duration,  more 
extensive  attachments,  larger  size,  and,  with  this  last,  the  certainty  of 
a  more  extensive  pedicle  and  numerous  large  sinus-like  vessels,  the 
question  of  deformity  and  disfigurement  must  be  entirely  set  aside  * 
In  order  to  secure  adequate  space  for  making  certain  of  all  the  attach- 
ments of  the  tumor,  for  eradicating  these,  and,  at  the  same  time, 
satisfactorily  meeting  the  haemorrhage  wdiich  is  usually  inevitable,  a 
freer  removal  of  bone  will  be  required.  No  doubt,  for  this  purpose, 
removal  of  the  upper  jaw  would  be  the  best  preliminary  step.  Every 
surgeon  who  has  performed  this  operation  knows  how  free  is  the 
access  which  it  gives  to  the  back  of  the  nose  and  to  the  pharynx.  A 
further  advantage,  pointed  out  by  Dr.  Sands,  is  the  following,  that, 
owing  to  the  wide  gap  left  by  this  operation,  recurrence  of  the  disease 
can  be  more  readily  recognized  and  treated  than  after  an  osteoplastic 
operation. 

But  while  willingly  admitting  the  great  advantages  which  removal 
of  the  upper  jaw  gives  for  free  exposure  of  the  growth,  I  cannot  quite 
agree  with  Dr.  >Sands,t  who  recommends  this  step  on  the  ground  that 
"  excisions  of  the  upper  jaw  are,  as  a  class,  remarkably  successful 
operations."  On  the  contrary,  I  should  look  upon  this  as  a  distinctly 
serious  and  grave  operation,!  especially  in  patients  who,  though 
young,  often  come  before  the  surgeon  with  strength  reduced  by  haem- 
orrhages, dysphagia,  and  dyspnoea,  especially  when  this  is  accom- 
panied by  attacks  of  clioking  interfering  with  sleep,  etc.  On  this 
account  I  should  prefer  to  try  and  get  at  the  growth  by  some  partial 
resection  of  this  bone,  as  by  the  method  of  Maisonneuve,  aided,  if 
need  be,  by  cutting  away  the  jjterygoid  process  and  septum  §  if  need- 

*  I  may  again  remind  tlie  reader  that  tliese  naso-pharyngeal  polypi  usnaily  occur 
in  males,  often  in  lads  or  young  adults.  The  growth  of  iiair  wiiicii  can  usually  be 
secured  in  these  cases  lessens  to  a  considerable  degree  the  amount  of  disfigurement 
which  operations  on  a  larger  scale  entail. 

t  Loc.  supra  cit.,  p.  516. 

X  !See  the  remarks  on  the  mortality  of  reuioval  of  the  upper  jaw,  p.  277. 

?  So  as  to  expose  completely  any  outlying  attachments  in  the  pterygoid  and  zygo- 
matic fossae,  and  to  get  full  access  to  the  pharynx  and  nose. 


292  OPERATIONS    ON   THE    HEAD    AND    NECK. 

• 

ful,   only   resorting    to   more   complete    removal   when   the   partial 
operation  does  not  give  sufficient  room. 

Dangers  and  Drawbacks  of  Osteoplastic  and  other 
Operations  for  Naso-pharyngeal  Polypus. — Many  of  these 
have  heen  ah-eady  given  under  the  liead  of  removal  of  the  upper  jaw, 
p.  276 ;  other  ones,  more  particularly  to  be  expected  here,  are : 

1.  Haemorrhage,  not  from  large  arteries,  as  the  internal  maxillary, 
but  from  the  sinus-like  veins  in  the  growth  itself.  To  meet  this 
inevitable  risk  a  preliminary  laryngotomy  should  be  performed,  and 
the  fauces  plugged  with  sponge. 

2.  Meningitis,  from  damage  to  the  base  of  the  skull  (p.  280),  or 
from  inflammation  spreading  to  the  membrane  of  the  brain. 

3.  Necrosis  and  exfoliation. 

4.  Non-union  of  the  temporarily  resected  fragment. 

TAPPING  THE  ANTRUM. 

This  operation  is  from  time  to  time  required  for  suppuration  in  the 
antrum,  nearly  always  in  adults,  and  most  frequently  after  alveolar 
abscess. 

It  may  be  performed  in  either  of  the  following  ways:  (i.)  Through 
the  alveolar  process,  (ii.)  Through  the  fticial  aspect  of  the  upper 
jaw,  above  the  alveolar  process. 

(i.)  Throvfjh  the  Alveolar  Process. — This  method  has  the  following 
advantages  :  (a)  It  drains  the  cavity  at  the  most  dependent  part. 
(/?)  By  withdrawal  of  the  tooth  at  the  same  time  it  removes  the  cause 
of  the  trouble,     (y)  It  does  not  involve  any  cutting. 

The  disadvantage  connected  with  this  method  is,  that,  unless  special 
precautions  are  taken,  food  tends  to  enter  the  antral  cavity  by  the 
opening  made  by  this  method. 

A  tooth  has  usually  to  be  first  drawn,  and,  as  long  ago  pointed  out 
by  Mr.  Salter,*  "  the  tooth  whose  fangs  are  most  intimately  connected 
with  the  antrum  is  the  first  permanent  molar;  f  and  its  removal  in  a 
case  of  antral  abscess,  is  especially  indicated  from  this  circumstance, 
and  from  the  frail  and  perishable  nature  of  the  tooth  itself,  which 
gives  it  less  often  than  other  teeth  a  long  tenure  of  usefulness."  This 
being  done,  the  orifice  made  should  be  enlarged  by  pushing  a  trocar 
up  through  the  alveolus.  In  doing  this  the  trocar,  closed,  should  be 
of  sufficient  size  to  ensure  a  free  orifice,  and,  in  driving  it  up  through 
the  bone,  care  should  be  taken  that  when  it  enters  the  antrum,  it 
should  not  plunge  against  and  perforate  the  orbital  plate. 

*  Syst.  of  Surg.,  vol.  ii.  p.  467. 

t  Any  other  tooth,  as  Mr.  Salter  advises,  molar,  bicuspid,  or  canine,  whose  disease 
is  possibly  the  cause  of  the  abscess,  will,  of  course,  be  extracted,  as  absorption  round 
any  carious  tooth  facilitates  perforation  of  the  alveolus. 


REMOVAL    OF    THE    LOWER   JAW.  293 

(ii.)  Above  the  Alveolar  Process. — If  the  offending  tooth  has  ah-eady 
been  extracted,  perhaps  a  long  time  before,  if  the  alveolar  process  is 
largely  absorbed,  or  its  remains  condensed,  it  will  be  preferable  to 
make  the  opening  above.  This  may  be  effected  by  everting  the  cheek, 
incising  the  mucous  membrane,  and  thus  exposing  the  bone  above 
the  position  of  the  second  molar  tooth,  and  then  perforating  here 
with  a  gimlet,  drill,  stout  trocar,  or,  as  Sir  B.  Brodie  suggested,  with 
a  strong  pair  of  scissors,  held  closed  in  the  hand  and  bored  into  the 
bone  with  a  twisting  movement. 

Where  the  bone  is  much  condensed,  the  instrument  used  in  per- 
forating will  be  held  so  tightly  that  the  surgeon  will  need  to  withdraw 
it  once  or  twice  and  use  a  probe  before  he  can  make  certain  of  having 
opened  the  antrum. 

The  antrum  having  been  opened  by  one  of  the  above  methods,  the 
chief  objects  to  be  held  in  view  are,  getting  and  keeping  sweet  the 
cavity  of  the  antrum  and  preventing  any  food  making  its  way  in  here, 
while  at  the  same  time  the  artificial  opening  is  kept  patent. 

To  ensure  these  ends  frequent  syringing  through  a  gum  elastic 
catheter  or  an  Eustachian  catheter  must  be  made  use  of,  the  lotion 
used  being  mercury  perchloride,  carbolic  acid,  iodine  tincture,  potas- 
sium permanganate — the  lotion  itself  not  being  of  so  much  importance 
as  the  assiduous  frequency  with  which  it  is  used.  After  a  while, 
when  the  discharge  is  no  longer  offensive,  and  no  inspissated  putty- 
like stuff  comes  away,  some  such  astringent  as  silver  nitrate  (gr.  1  or 
2-5J)  may  be  used.* 

To  prevent  the  entrance  of  food,  and  at  the  same  time  to  keep  the 
opening  patent,  a  short  tube  should  ])e  Avorn,  let  into  a  plate  fitted 
over  the  perforation.  Through  this  tube  the  patient  can  readily 
syringe  out  the  cavity  and  by  the  insertion  of  a  small  plug  of  cork  at 
meal-times  the  entrance  of  food  can  easily  be  prevented.  When 
there  is  no  longer  any  need  to  keep  the  artificial  opening  patent,  re- 
moval of  the  short  tube  and  soldering  up  the  hole  which  held  it,  will 
facilitate  the  closure  of  the  antral  opening  by  excluding  air,  saliva, 
etc.  If  the  complete  closure  is  still  tardy,  it  may  be  hastened  by  the 
careful  application  of  the  cautery. 

REMOVAL  OF  THE  LOWER   JAW,  PARTIAL  OR 
COMPLETE. 

Indications. — These  are  much  the  same  as  those  already  fully 
given  for  removal  of  the  upper  jaw,  p.  267.     Mr.  Butlinf  has  recently 


*  The  patient  should  be  wiirned  at  the  commencement  how  very  tedious  tiiese  cases 
are,  and  told  of  the  need  of  persevering  and  patiently  prolonged  treatment. 
t   Oper.  Treat,  of  Malig.  Dis.,  p.  137. 


294  OPERATIONS    ON    THE    HEAD    AND    NECK. 

treated  of  these  growths,  and  has  pointed  out  that  here  great  differ- 
ences are  observable  between  the  central  and  sub-periosteal  sarco- 
mata. Thus  the  central  (most  often  myeloid)  sarcomata  grow  slowly, 
the  sub-periosteal  quickly ;  the  former  are  encapsuled,  and  even  when 
they  make  their  way  into  the  surrounding  structures  they  do  not 
show  that  tendency  to  infiltration  which  is  so  marked  in  the  sub- 
periosteal sarcomata.  The  central  ones  are  rarely  associated  with 
affection  of  the  lymphatic  glands,  or  with  secondary  growths. 
The  following  operations  will  be  considered  : 

A.  Partial  removal  of  the  lower  jaw. 

B.  Complete  removal  of  one-half  of  the  lower  jaw  (Fig.  62). 

C.  Com])lete  removal  of  the  jaws,  upper  or  lower. 

A.  Partial  Removal  of  the  Lower  Jaw.— This  is  frequently 

required  in  cases  of  epulis.  The  steps  are  the  same  as  those  given 
already  at  p.  268.  The  alveolar  border  should  always  be  removed ; 
in  the  case  of  a  growth  very  far  back  around  the  lower  molars  it  is 
quite  justifiable  to  slit  the  cheek,  especially  if  the  growth  is  becoming 
doubtful  in  character,  and  thus  requires  thorough  extirpation. 

The  above  remarks  still  more  hold  good  in  the  case  of  a  growth 
about  the  gums,  situated  far  back  in  an  older  patient,  and  becoming 
epitheliomatous. 

Cases  are  occasionally  met  with  where,  owing  to  an  epithelioma  of 
the  lip  not  having  been  treated,  or  to  its  recurrence,  the  symph3'sis  of 
the  jaw  is  infiltrated  and  requires  removal.  The  soft  parts  being  re- 
flected by  incisions  on  either  side  of  the  diseased  parts  converging 
towards  the  hyoid  bone,  and  the  vessel  secured,  the  bone  is  sawn 
through  in  two  places*  well  beyond  the  level,  where  its  softened, 
spongy  state,  and  the  loosened  teeth,  show  that  it  is  invaded.  The 
tongue,  prevented  from  falling  back  by  a  loop  of  silk  passed  through 
its  tip,  is  now  detached  by  snipping  through  the  mucous  membrane, 
and  the  muscles  attached  to  the  genial  tubercles.  Any  further  haem- 
orrhage being  looked  to,  the  sub-lingual  sub-maxillary  glands  are 
examined,  and,  together  with  any  enlarged  lymphatic  glands,  re- 
moved if  needful ;  flaps  are  dissected  up  from  the  neck  to  make  a 
new  lip  (p.  315,  Figs.  72,  73),  and  drainage  provided,  the  tubes  being 
brought  out  below  at  the  lowest  level  of  the  region  from  which  the 
flaps  have  been  dissected  up.  The  adjustment  of  these  to  form  the 
new  lip  will  be  the  more  easy  in  proportion  to  the  amount  of  bone 
which  has  been  removed. 

*  Mr.  Heath  [Dirt,  of  Surg.,  vol.  i.  p.  839)  gives  the  following  practical  hint  with 
reference  to  dividing  the  jaw  in  two  places:  "In  making  these  sections  it  is  better  not 
to  complete  one  before  the  other  is  begun,  because  of  the  loss  of  resistance  consequent 
upon  breaking  the  continuity  of  the  bone,  but  each  cut  being  carried  nearly  through 
the  bone  with  the  saw  may  be  conveniently  finished  with  the  bone- forceps," 


REMOVAL    OF    THE    LOWER    JAU^  295 

So,  too,  occasionally  in  epithelioma  of  the  angle  of  the  jaw,  primary 
or  secondary  to  that  of  the  tongue,  the  surgeon  may  be  led,  in  order 
to  relieve  his  patient's  condition,  if  he  cannot  cure  him,  to  operate 
extensively  here.  Thus,  after  turning  up  a  horseshoe-shaped  flap, 
with  the  concavity  upwards,  and  clearing  the  masseter  off  the  jaw, 
this  bone  is  divided  above  the  angle,  then  through  the  horizontal 
ramus,  and  removed,  together  with  the  sub-maxillary,  sub-lingual, 
and  lymphatic  glands,  Avhich  will  probably  be  enlarged,  and  also  ad- 
herent. The  haemorrhage  will  certainly  be  free  from  the  facial  and 
lingual  vesssls,  and  veins  communicating  with  the  external  jugular. 
Free  drainage  must  be  provided. 

Removal  of  part  of  the  horizontal  ramus  or  of  the  angle  is  some- 
times called  for  in  cases  of  new  growths  Avhich  are  limited  to  these 
parts,  and  the  surgeon  may,  especially  in  the  cases  of  women,  ask  how 
far  it  is  worth  while  to  try  and  remove  these  from  the  mouth,  detaching 
the  soft  parts  with  a  raspatory,  and  sawing  the  bone  in  front  and  be- 
hind the  growth,  as  in  the  case  of  an  epulis,  but  the  section  here  pass- 
ing through  the  whole  thickness  of  the  jaw.  Mr.  Maunder  on  two 
occasions  removed  large  portions  of  the  bone  in  this  way.  The  follow- 
ing remarks  of  Mr.  Heath*  should  be  carefully  considered  before  the 
surgeon,  for  the  sake  of  saving  a  scar  which  will  be  ver}^  little  noticed, 
undertakes  a  much  more  difficult  operation,  and  one  which,  owing  to 
the  limited  space  it  gives,  may  tend  to  his  working  dangerously  near 
the  growth :  "  The  principal  difficulty  in  these  operations  was  not  so 
much  the  separation  of  the  tumor,  as  its  '  delivery  '  through  the  mouth, 
which  was  slightly  split  in  one  instance.  Fortunately  the  haemor- 
rhage in  both  cases  was  slight,  and  the  patients  did  well ;  but  another 
surgeon  was  less  fortunate,  and  lost  his  patient  by  secondary  hfemor- 
rhage,  but,  considering  the  close  proximity  of  the  facial  artery,  and 
the  necessary  division  of  the  inferior  dental  artery,  this  is  not  to  be 
wondered  at.  It  may  be  doubted  if  the  extra  trouble  and  risk  of  the 
proceeding  are  balanced  by  the  absence  of  a  scar,  whicli,  in  the  ma- 
jority of  cases,  need  not  involve  the  lip,  and,  if  properly  placed,  will 
be  nearly  invisible  afterwards." 

Question  of  Reinovinff  a  Portion  or  the  Whole  of  One  Lower 
Jaw. — This  matter  will  have  to  be  decided  when  the  surgeon,  having 
a  case  of  growth  before  him  which  involves  the  horizontal  ramus  as 
far  back  as  the  angle,  is  in  doubt  as  to  whether  to  saw  through  the 
horizontal  ramus  or  to  disarticulate.  In  the  great  majority  of  cases, 
especially  where  the  patient  is  no  longer  young,  where  the  growth  is 
not  a  central  one,  Avhere  it  has  been  attacked  before,  the  operator  had 
much  best  place  his  patient  and  himself  on  the  safe  side  and  disar- 
ticulate.     The  lower  jaw  being  "  a  floating  bone,"  this  radical  step 

*  Diet,  of  Surg.,  vol.  i.  p.  837. 


296 


OPERATIONS    ON    THE    HEAD    AND    NECK. 


often  gives  a  better  prognosis  for  operation  here  than  in  the  case  of 
the  upper  jaw.  On  the  other  hand,  the  lower  jaw  is  so  imbedded  in 
soft  parts,  and  so  near  to  important  parts — e.g.,  pharynx  and  ptery- 
goid fossie — that  delay  may  render  the  extirpation  of  the  growth  im- 
possible. I  would  refer  my  readers  to  two  cases  in  which,  after  par- 
tial operations,  even  in  Mr.  Heath's  hands  (Hunt.  Lects.,  Brit.  Med. 
Journ.,  June  18  and  July  2,  1887)  fatal  extension  and  recurrence  of 
the  growth  took  place. 

B.  Removal  of  Half  of  the  Lower  Jaw  (Fig.  62).— The 
patient's  shoulders  being  supported  and  a  preliminary  laryngotomy 
performed  if  the  growth  is  so  vascular  as  to  make  plugging  of  the 
fauces  a  wise  precaution,  the  surgeon,  standing  usually  on  the  same 
side,  makes  an  incision  from  just  below  the  lip*  down  through  the 
tissues  on  the  side  of  the  chin,  then  along  ai.d  below  the  border  of  the 
lower  jaw  to  the  angle,  and  then  upwards  as  high  as  the  lobule  of  the 
ear.  The  finger  of.an  assistant  is  placed  on  the  facial  artery  as  soon 
as  it  is  cut  in  this  incision,  and  when  it  is  completed  the  ends  should 
be  tied  or  twisted  at  once.  The  flap  thus  marked  out  is  raised  up- 
wards, the  masseter  going  with  it  if  sound,  and  the  cavity  of  the  mouth 
opened  by  dividing  the  buccal  mucous  membrane  at  its  junction  with 

the  alveolar  border.  An  incisor 
being  extracted  if  needful,  the  jaw 
is  divided  to  one  side  of  the  sym- 
pliysis  well  in  front  of  the  growth, 
by  means  of  deeply  notching  it  with 
the  sawf  before  using  the  bone-for- 
ceps. If  it  be  needful  to  remove 
the  bone  so  freely  that  the  symphy- 
sis and  the  genial  tubercles  are  re- 
moved also,  the  tongue  must  be 
carefully  prevented  from  falling  back 
upon  the  larynx  by  means  of  a  loop 
of  stout  silk  passed  through  the  tip. 
The  bone  being  divided  and  pulled  outwards  the  knife  is  passed  along 
the  inner  side  of  the  jaw  so  as  to  detach  the  mylo-hyoid,  with  perhaps 
the  digastric  and  the  mucous  membrane,  and  at  the  angle,  the  inter- 


FiG.  62. 


*  If  there  are  reasons  for  especial  speed,  such  as  tlie  condition  of  the  patient,  or  if 
the  ^rowtli  is  very  large,  tiie  red  border  should  be  divided,  as  this  facilitates  matters 
much,  and  the  additional  deformity  is  very  slight. 

t  When  the  condition  of  things  admits  of  it,  the  jaw  should  always  be  divided  as 
far  from  the  symphysis  as  possible,  in  order  to  preserve  the  anterior  belly  of  the  di- 
gastric and  its  insertion,  which  will  thus  counteract  the  tendency  of  the  nuiscleson  tiie 
opposite  side  to  draw  tiie  chin  somewhat  over.  It  is  convenient  to  be  provided  with 
a  saw  with  a  movable  back. 


EEMOVAL    OF    THE    LOWER    JAW.  297 

nal  pterygoid.  In  doing  tins  the  knife  should  he  kept  very  close  to 
the  line  so  as  to  leave  behind  the  sub-maxillary  gland. 

The  anterior  half  of  the  jaw  being  thus  freed,  the  surgeon,  taking  it 
in  his  left  hand,  everts  it  so  as  to  divide  the  internal  pterygoid  more 
freely,  and  also  the  inferior  dental  nerve  and  vessel?.  The  jaw  is  next 
strongly  dei)ressed  so  as  to  bring  down  the  coronoid  process,  and  the 
insertion  of  the  temporal  muscle.  This  strong  tendon  requires  com- 
plete division,  as  depression  of  the  bone  brings  fasciculus  after  fasci- 
culus into  view.  If  the  coronoid  process  is  very  long  it  may  hitch 
against  the  malar  bone  or  be  jammed  against  it  by  the  bulk  of  the 
tumor:  in  such  case  it  had  better  be  cut  off  with  bone-forceps,  and, 
after  the  removal  of  the  growth,  dragged  down  with  sequestrum-for- 
ceps and  removed.  After  the  temporal  tendon  is  thoroughly  detached* 
strong  depression  of  the  jaw  is  continued  so  as  to  bring  the  condyle 
within  reach,  no  aversion  or  rotation  outwards  of  the  bone  being  per- 
missible at  this  stage  of  the  operation,  or  the  internal  maxillary  artery 
which  passes  between  the  neck  of  tlie  jaw  and  the  internal  lateral  lig- 
ament will  be  brought  into  the  wound,  and  very  likely  cut,  causing 
profuse  and  troublesome  haniiorrhage.  The  inferior  dental  nerve  and 
vessels  being  divided,  and  the  external  pterygoid  fibres  partly  torn 
through  with  the  finger  or  the  director,  the  capsular  ligament  is 
opened  in  front  with  the  careful  use  of  the  point  of  the  knife,  which 
next,  kept  close  to  the  bone,  divides  the  lateral  ligaments,  when  the 
jaw  comes  away,  the  final  operation  being  usually  effected  by  the  re- 
maining fibres  of  the  external  pterygoid  being  torn  through,  together 
with  the  stylo-maxillary  ligament  and  the  periosteum  to  which  it  is 
attached.  The  knife,  if  it  is  required  here,  should  be  kept  very  closely 
in  contact  with  the  posterior  border  of  the  ascending  ramus. 

If  the  internal  maxillary  artery  has  been  divided,  which  is  some- 
times excusable  in  cases  of  large  growths  extending  far  up,  it  can  be 
readily  secured  in  the  large  wound. 

If  the  operator  finds  the  vertical  part  of  his  incision  insufficient, 
and  yet  does  not  like  to  prolong  it  for  fear  of  damaging  the  chief  part 
of  the  seventh  nerve,  the  soft  parts  should  be  forcibly  dragged  up^ 
wards  with  a  retractor,  after  being  pushed  upwards  with  the  handle  of 
the  scalpel. 

In  cases  where  the  jaw  has  been  extensively  thinned  or  eroded  by 
growth,  it  is  very  likely  to  fracture  under  the  depression  which  is  re- 
quired to  bring  down  the  condyle.  If  this  accident  occur,  removal  of 
the  condyle  and  coronoid  process  is  rendered  difficult,  as  the  latter  is 
drawn  upwards  under  the  zygoma  by  the  temporal  muscle.  Their 
removal  will  be  facilitated  by  dragging  them  down  with  lion-forceps 
and  detaching  the  temporal  tendon  with  blunt-pointed  scissors. 

*  When  this  is  effected  the  jaw  comes  down  more  easily, 


298  OPERATIONS    OX    THE    HEAD    AND    NECK. 

All  haemorrhage  being  arrested  by  ligature  or  sponge-pressure,  the 
flap  is  brought  down  and  adjusted  with  one  or  two  points  of  silver 
suture  and  sutures  of  horsehair,  gut,  or  carbolized  silk,  drainage  being 
first  provided  for  by  bringing  a  drainage-tube  from  the  neighborhood 
of  the  condyle  through  the  wound  below. 

Especial  care  must  be  taken  in  exactly  uniting  the  red  line  of  tlie  lip 
if  this  has  been  divided. 

The  wound  is  then  dressed,  as  at  p.  275',  and  the  patient  here  also 
should  be  propped  up  to  facilitate  escape  of  the  discharges. 

Difficulties  and  Possible  Mistakes  during  the  Operation. 

1.  Slipping  back  of  the  tongue,  if  the  symphysis  has  been  re- 
moved. 

2.  AVound  of  the  pharjmx  by  not  keeping  the  knife  close  t(ithe  bone 
in  separating  the  soft  parts  from  the  angle  of  the  jaw.  This  interferes 
with  the  patient's  being  able  to  swallow  from  the  very  first. 

3.  Fracture  of  the  jaw. 

4.  Jamming  of  the  coronoid  process. 

5.  Rigidity  and  permanent  contraction  of  the  temporal,  masseter, 
etc. 

6.  Wound  of  the  internal  maxillary  vessels. 

C.  Operations  for  Complete  Removal  of  Both  Jaws. 

Before  leaving  the  subject  of  removal  of  the  jaws,  a  few  words  may 
be  said  of  those  rare  cases  which  occasionally  call  for  removal  of  both 
the  upper,  or  the  Avhole  of  the  lower  jaw.  My  space  does  not  admit 
of  my  doing  more  than  giving  brief  references  to  a  few  cases.  The 
chief  conditions  calling  far  such  extensive  operations  are  phosphorus 
necrosis  in  the  case  of  the  upper  or  lower  jaws.  The  diminishing  fre- 
quency of  this  disease  is  well  known  ;  where  the  whole  of  the  upper  or 
lower  jaw  requires  removal,  half  should  be  taken  first,  and  the  opera- 
tion should  be  conducted,  as  far  as  possible,  sub-periosteally  and  Avith- 
out  skin  incisions. 

The  growths  which  call  for  removal  of  both  upper  jaws,  simultane- 
ously, fall  mainly  under  the  two  heads — («)  Epithelioma  of  the  palate 
and  alveoli  involving  one  or  both  of  the  antra.*  (yJ)  Growths,  usually 
sarcomatous,  springing  often  from  the  base  of  the  skull  or  some  part 
of  the  naso-pharynx,  and  projecting  forwards  the  jaws  with  hideous 
deformity .f  These  cases  are  much  less  favorable  than  the  epithe- 
liomata. 

In  either  case  the  parts  are  exposed  by  slitting  the  centre  of  the 
upper  lip  and  then  carrying  the  incision  round  the  nose  on  either  side, 
Fergusson's  incision  being  made  use  of  as  far  as  needful.     After  the 

*  Godlee,  Clin.  Soc.  Trans.,  vol.  xx.  p  260. 

f  Lane,  Lancet,  January  25,  1862;  Dobson,  Brit.  Med.  Journ.,  October  11,  1873. 


EEMOVAL   OF    THE    LOWER    JAW.  299 

full  account  already  given  of  removal  of  the  upper  jaw  no  description 
need  be  given  of  these  operations  for  removal  of  both  halves  simul- 
taneousl3\  The  greater  risk  of  shock,  the  liability  to  more  profuse 
hemorrhage,  the  probabilit}'  of  finding  the  growth  extending  far  back 
into  the  different  fossae,  and  along  the  base  of  the  skull,  are  obvious. 
Later  on,  if  the  patient  make  a  good  recovery,  the  help  of  a  dentist 
will  be  much  needed  in  fitting  some  form  of  obturator,  as  articulation 
is  now  much  more  imperfect. 

Question  of  Gouging,  etc.,  in  preference  to  Partial  Re- 
moval of  the  Jaw. 

The  treatment  of  dentigerous  cysts,  if  simply  cystic  and  uncompli- 
cated by  growth,  by  measures  short  of  removal  of  part  of  the  jaw,  has 
already  been  given  (p.  270).  The  same  treatment  Avill  suggest  itself 
in  other  cases,  esj^ecially  those  cases  of  cystic  disease,  more  common 
in  the  lower  than  in  the  upper  jaw,  the  multilocular  variety  of  which 
will  perhaps  be  known  for  the  future,  in  Mr.  Eve's  words,*  as  cystic 
epithelial  tumors. 

The  treatment  of  cystic  tumors  of  the  jaw,  whether  single  or  multi- 
locular, has  usually  been  extraction  of  any  teeth  which  are  in  the  way, 
freely  opening  uj^  the  cyst  by  cutting  away  part  of  its  walls,  turning 
out  its  Contents,  and  then  obliterating  it  thoroughly  by  vigorously 
gouging  wide  of  the  disease. 

Any  surgeon  proposing  to  make  use  of  this  method,  in  preference 
to  more  radical  means,  should  weigh  thoroughly  the  sentences  with 
which  Mr.  Heath  closed  his  Hunterian  lecture  on  this  subject.  "  I 
have  now  treated  a  considerable  number  of  simple  and  multilocular 
cysts  by  Mr.  Butcher's  method,t  and,  as  has  been  noted,  with  recur- 
rence in  at  least  two  of  tlie  latter.  Mr.  Butcher  does  not  appear  to 
have  met  with  further  trouble  in  his  cases,  and  this  may  depend  upon 
his  carrying  out  the  gouging  fearlessly  and  far  wide  of  the  disease." 
I  should,  in  future,  be  guided  by  the  age  of  the  patient,  and  the 
amount  of  the  solid  material  found  in  the  cysts.  In  young  persons 
with  cysts  having  fluid  contents  and  little  growth  in  tlie  bone,  I 
should  be  still  inclined  to  adopt  palliative  measures,  and  to  gouge 
very  freely,  carefully  watching  the  case  with  a  view  to  a  more  radical 
proceeding,  should  further  development  take  place.  In  cases  of  much 
solid  deposit  in  connection  with  multilocular  cysts,  and  still  more  in 

*  Mr.  Eve  {Brit.  Med.  Journ.,  January  6,  1883)  believes  that  many  of  these  cysts 
are  produced  by  an  ingrowth  of  the  epithelium  of  the  gum. 

+  I.e.,  by  cutting  away  the  expanded  bone  freely  and  then  using  the  gouge.  In  Mr. 
Butcher's  words:  "the  proceeding  according  to  this  plan  is  troublesome  and  difficult, 
but  its  value  to  the  patient  in  liaving  no  deformity  left  is  priceless."  A  caution  is 
given  respecting  the  facial  artery,  which  might  without  care  be  divided  from  within 
the  mouth  in  a  position  where  it  would  be  very  difficult  to  secure  it  (p.  205). 


300  OPERATIONS    ON    THE    HEAD    AND    NECK. 

solid  tumors  with  one  or  more  large  cysts,  there  should,  I  think,  be  no 
doubt  as  to  the  removal  of  one-half  or  more  of  the  lower  jaw,  or  of  any 
portion  of  the  upper  jaw  *  involved. 


OPERATIONS   TO    RELIEVE   FIXITY  OF  THE  LOWER 

JAW. 

The  above  condition  may  be  due  either  to  changes  in  the  temporo- 
^iiaxillary  articulation  resulting  in  ankylosis,  or  to  cicatricial  bands 
between  the  jaws,  or  to  both. 

Operations. — The  two  usually  performed  are  : 

(i.)  Excision  of  the  condyle,  an  oj^eration  indicated  when  the  mis- 
chief is  limited  to  the  joint  itself. 

(ii.)  Esmarch's  operation  of  removing  a  wedge  of  bone  from  the 
horizontal  ramus  in  front  of  the  cicatrices  and  masseter,  this  operation 
being  preferable  to  the  first  when  scars  are  present  which  interfere 
with  excision  of  the  condyle. 

Condiuons  justifying  One  of  the  Above  Operations. — 
Inability  to  open  the  mouth,  resisting  the  use  of  wedges,  etc.  Foetor 
of  saliva  and  breath.  Difficulty  of  speech.  Inability  to  eat  solid 
food.  The  above  are  brought  about  by  the  following  causes,  which 
will  be  enumerated  together  here,  though  some  call  for  one  of  the 
above  operations  and  some  for  the  other — viz. : 

1.  Inflammation  of  the  joint  set  up  by  a  punctured  wound,t  gonor- 
rhoea! arthritis,  severe  contusion  X  or  sprain,  osteo-arthritis,  or  suppu- 


*  Mr.  Lawson  broiiglit  before  tlie  Clinical  Society  [Trans.,  vol.  vi.  p.  20)  the  caseof 
a  man,  aged  sixty-five,  in  which  he  succeeded,  by  excision  and  application  of  zinc- 
chloride  paste,  in  extirpating  an  epithelioniatons  growth  of  the  npper  jaw  fungating 
throiigii  the  skin  of  the  face.  Tlie  growth  recnrred  twice  during  convalescence,  and 
on  each  occasion  an  anaesthetic  was  given,  and  the  actnal  cantery  and  the  zinc-chloride 
paste  applied.  Mr.  Lawson  points  ont — (1)  tiiat  patients  advanced  in  life  stand  large 
cutting  operations,  such  as  the  complete  removal  of  the  npper  jaw,  very  badly,  whilst 
they  will  bear  with  but  little  shock  the  destruction  of  large  growths  by  escharotics; 
(2)  that  the  treatment  was  accompanied  with  very  little  paiij;  (3)  that  the  deformity 
produced  by  such  an  operation  is  much  less  tlr.m  that  after  an  equally  efficient  opera- 
tion by  the  knife  which  would  have  involved  cutting  widely  of  the  growth.  It  is  to  be 
regretted  that  no  details  are  given  of  how  the  growth  was  excised,  nor  of  how  much 
of  the  bone  was  removed.  Furthermore,  the  report  is  only  carried  on  four  months 
after  the  patient's  leaving  the  hospital. 

t  Cf.  Mr.  Hilton's  case  (Rest  and  Pain,  p.  114),  in  which  bony  ankylosis  of  this 
joint,  and  of  the  npper  cervical  vertebrae,  seemed  to  date  to  a  punctured  wound  in  the 
neck. 

X  Mr.  Heatii  [E.C.S.  Ledn.,  1887,  vol.  ii.  p.  114)  mentions  a  case  in  which  anky- 
losis of  the  temporo-maxillary  joint  followed  on  a  kick  from  a  horse  on  the  side  of  the 
face. 


FIXITY    OF    THE    LOWER   JAW.  301 

rative  arthritis,  from  abscesses  burrowing  into  the  joint,  e.g.^  abscesses 
connected  with  otitis  media. 

2.  An  unreduced  dislocation  in  which  in uch  stiffness  remains  after 
attempts  at  reductions  have  failed  in  a  patient  health^^  and  not 
advanced  in  life. 

3.  Cicatrices  after  sloughing  set  up  by  scarlet  fever,  measles,  tophus, 
cancrum  oris,  or  mercurial  stomatitis. 

4.  Cicatrices  after  suppuration  due  to  necrosis  or  alveolar  abscess. 
Excision  of  the  Condyle.— This  operation  is  indicated  when 

the  mischief  is  limited  to  the  joint  itself,  as  in  the  first  two  conditions 
given  above. 

It  may  be  performed  as  follows : 

An  incision  about  1?  inch  long  is  made  on  a  level  with  the  tragus 
along  the  lower  border  of  the  zygoma.  The  parotid  and  branches  of 
the  facial  nerve  being  drawn  down,  the  masseter  fibres  are  cleared 
away  from  their  insertion  with  a  narrow  elevator,  and  the  joint  ex- 
posed. The  neck  of  the  condyle  is  now  sawn  through  with  a  fine  saw, 
or  divided  with  an  osteotome,  and  the  condyle  turned  out  with  an 
elevator.  The  bone,  which  must  not  be  splintered,  may  require  fur- 
ther paring  down,  and  the  operation  need  repeating  on  the  opposite 
side  before  sufficiently  free  movement  is  regained.  After  the  operation 
the  mouth  should  be  opened  with  a  gag  to  a  full  inch,  more  if  pos- 
sible, and  this  should  be  frequent!}^  repeated,  and  the  case  watched 
most  carefully  owing  to  the  frequency  with  which  relapses  take  place.* 

Prof.  Humphry!  made  use  of  the  following  method  in  a  woman, 
aged  twent^'-one,  many  years  ago.    The  case  was  one  of  osteo-arthritic 

*  1  may  here  quote  some  remarks  made  in  my  article  ''On  Injuries  of  the  Face" 
{Syst.  of  Surg.,  vol.  i.  p.  728)  when  discussing  the  causes  of  the  early  and  marked 
fixity  of  the  jaw  after  an  unreduced  dislocation.  "It  is  more  probable  that  the  dis- 
placed coronoid  process  and  the  neighboring  parts  of  the  ramus  become  quickly 
imbedded  in  inflammatory  products,  which,  in  this  region  especially,  are  so  rapidly 
effused,  and  which  here  so  sf)on  undergo  at  least  partial  organization,  leading  perhaps 
not  only  to  fixity  of  the  displaced  condyle  and  coronoid  process,  but  also  to  filling  up 
of  the  glenoid  cavity.  This  consolidation  of  effused  inflammatory  products  will  be 
hastened  by  the  patient,  owing  to  the  pain,  keeping  his  jaw  as  quiet  and  fixed  as 
possible." 

t  A  Report  nf  Some  Cases  of  Operation.  Pamph.  18o6.  Some  interesting  cases  of  the 
same  kind  (one  occurring  in  a  woman  aged  tiiirty),  with  figures,  are  given  by  Mr. 
Heath  (loc.  supra  cit.,  July  9,  1887).  Two  other  modes  of  treatment  are  here  given — 
viz.,  subcutaneous  division  of  the  adhesions  between  the  condyle  and  glenoid  cavity, 
as  practiced  by  Mr.  Spanton  with  good  results  in  two  cases  ;  and  division  of  the  ascend- 
ing ramus  beneath  the  magseter  by  a  saw  introduced  from  the  mouth  by  means  of  a 
small  incision  immediately  above  the  last  molar  tootli,  a  director  being  first  passed  to 
clear  the  way.  Mr.  Heath  had  found  this  operation  give  satisfactory  results  in  one 
case. 


302  OPERATIONS    ON    THE    HEAD    AND    NECK. 

alteration  of  the  right  condyle,  pushing  the  jaw  to  the  left,  and  caus- 
ing most  annoying  deformity  with  crepitus  in  mastication  : 

A  curved  incision  was  made  from  the  side  of  the  orbit  across  the 
zygoma  to  the  ear,  a  little  below  the  temporo-maxillary  joint,  and  a 
second  from  the  end  of  the  first  directly  upwards  in  front  of  the  ear, 
over  the  zygoma  again,  cutting  carefully  to  avoid  the  temporal  artery. 
The  flap  being  reflected,  the  condyle  was  brought  into  view,  and  the 
bone  divided  with  a  narrow  saw,  cutting  from  before  backwards. 
This  was  prolonged,  as  the  bone  was  hard  and  the  space  to  work  in 
confined.  When  the  condyle  had  been  turned  out  with  bone-forceps, 
it  was  found  that  the  section  had  passed  through  the  condyle,  and 
thus,  owing  to  insufficient  removal  of  bone,  the  jaws  could  not  be 
brought  into  apposition.  The  bone  was  accordingly  sawn  a  second 
time,  through  the  neck,  and  all  the  condyle  and  the  external  ptery- 
goid removed.  The  jaws  could  now  be  brought  into  much  better 
position.  The  facial  nerve  and  the  temporal  artery  were  not  cut.  The 
deformity  was  almost  entirely  removed,  and  the  patient  was  enabled 
to  masticate  without  inconvenience. 

Esmarch's  Operation. — Where  the  fixity  of  the  jaws  is  brought 
about  by  cicatrices  within  the  mouth  rather  than  by  mischief  limited 
to  the  joint,  removal  of  a  wedge-like  piece  of  bone  is  to  be  preferred. 

An  incision  2  or  2\  inches  long  is  made  along  the  lower  border  of 
the  jaw  in  front  of  the  masseter  and  cicatrices,  and  a  wedge  removed 
with  a  narrow  saw  and  bone-forceps.  The  sections  should  be  made 
as  cleanly  as  possible  to  avoid  risk  of  necrosis,  and  the  periosteum 
should  be  removed  with  the  bone.  The  wedge  should  measure  at 
least  li  inch  below  and  f  inch  above,*  and  it  must  be  taken  from  a 
part  entirely  in  front  of  any  cicatricial  tissue. 

Owing  to  the  tendency  to  relapse,t  passive  and  active  movements 
should  be  made  vise  of  early,  and,  at  first,  if  needful,  with  the  aid  of 
an  anesthetic. 

Dr.  MaasJ  relates  the  following  case:  A  man,  aged  twenty-seven, 
suffered  from  immobility  of  the  jaw,  dating  to  scarlatina  at  the  age 
of  seven.  Secondary  dentition  had  been  attended  with  great  diffi- 
culty in  the  removal  of  the  first  teeth,  the  permanent  ones  being 
irregularly  developed,  and  mostly  displaced  laterally.     There  was  not 

*  In  two  of  Mr.  Heath's  cases  the  wedge  removed  included  the  mental  foramen. 

f  This  relapse  is  more  likely  if  the  wedge  is  not  removed  well  in  front  of  all  cica- 
trices. Thus  Mr.  Heath  (Dis.  and  Inj.  of  the  Jems,  p.  332)  found,  two  years  after 
Esmarch's  operation  for  complete  closure  of  the  jaws,  that  the  interval  between  the  left 
molars  had  diminished  from  |^  to  ^  inch,  and  that  between  the  lateral  incisors  from 
I  to  I  inch.  Mr.  Heath  thought  that  in  this  case  he  had  not  been  sufficiently  careful 
to  make  the  bone  section  entirely  in  front  of  the  cicatrices. 

X  Arch.  f.  Klin.  Chiv.,  Bd   xiii.  Heft  3. 


HAEE-LIP.  303 

the  least  movement  under  anaesthesia.  Esmarch's  operation  performed 
on  both  sides  produced  movement  with  voluntary  painless  opening 
of  the  mouth  amounting  to  H  inch. 

The  above  shows  the  importance  of  operating  early  in  cases  where 
severe  ulceration  is  certain  to  lead  to  increasing  fixity  of  the  jaw, 
ultimately  needing  operative  interference. 

Mr.  Heath*  thus  states  his  opinion  of  Esmarch's  o})eration  :  It  is 
"  a  comparatively  easy  proceeding ;  and  in  cases  where  only  07ie  side 
of  the  jaw  is  affected,  restores  the  patient  a  very  useful,  though  one- 
sided, amount  of  masticatory  power  in  two  or  three  weeks,  and  with 
very  little  suffering  or  annoyance.  One  side  of  the  jaw  is,  however, 
rendered  permanently  useless  (its  previous  condition),  and  there  is  a 
necessarily  resulting  deformity,  which  is  not,  however,  of  a  very  dis- 
tressing character.  The  paralysis,  from  the  division  of  the  nerve,  is 
so  slight  as  not  to  be  worthy  of  mention." 


CHAPTER  VIII. 

OPERATIONS  ON  THE  LIPS. 

HARE-LIP  AND  OTHER  PLASTIO  OPERATIONS  ON 

THE  LIPS. 

HARE-LIP  (Figs.  63-71). 

Best  Time  for  Operation. — Any  time  after  the  second  or  third 
month.  For  most  cases  the  third  to  the  sixth  month  is  the  best.  All 
should  be  over  by  the  seventh  month,  when  dentition  begins. 

With  regard  to  operations  at  an  earlier  or  later  date  than  the  above, 
it  is  interesting  to  note  what  Sir  W.  Fergusson,  whose  experience  was 
unrivalled,  advocated  with  a  riper  experience.  Thus,  in  his  Prncticnl 
Surgery  (fourth  edition,  p.  578,  1857),  he  writes  :  "  I  have  myself  oper- 
ated very  frequently  within  the  first  three  weeks ;  "  and  a  little  later, 
"  From  all  my  reflections  and  experience  on  the  question,  I  am  more 
than  ever  disposed  to  recommend  a  very  early  operation."  In  his 
Royal  College  of  Surgeons  Lectures  on  the  Progress  of  Anatomy  and  Sur- 
gery (1867),  with  an  experience  of  between  300  and  400  cases,  he 
writes  :  "  I  decidedly  prefer  about  the  end  of  the  first  month."  Writing 
later  on  (Brit.  Med.  Journ.,  1874,  vol.  i.  p.  403),  Sir  WilHam  stated  that 
his  favorite  time  was  from  "  three  weeks  to  three  months." 

While  the  rule  of  British  surgery  is  to  get  the  operatian  over  before 

*  Loc.  supra  cit.,  p.  338. 


304  OPERATIONS    ON    THE    HEAD    AND    NECK. 

dentition,  many  German  surgeons  defer  taking  any  steps  till  the  child 
has  entered  on  the  second  year.  Thus  Prof.  Billroth*  announces  his 
practice  as  follows:  "Unless  the  parents  urgently  demand  an  opera- 
tion as  early  as  possible,  I  generally  prefer  to  operate  on  children 
when  they  are  more  than  one  year  old.  I  always  advise  this  in  strong 
children  AVith  complicated  hare-lips,  especially  when  the  inter-maxil- 
lary bones  are  displaced  and  the  hare-lip  is  double.  I  have  been  particu- 
larly satisfied  with  the  results  of  operation,  as  far  as  appearance  is 
'concerned,  on  children  at  rather  later  periods  of  life  and  in  adults." 
Some  further  remarks  of  Prof.  Billroth  are  quoted  at  p.  313. 

My  reasons  for  deferring  the  operation,  as  a  rule,  till  after  the  third 
month,  are — 

1>  That  the  difficulties  of  getting  children  with  haredip  to  take 
sufficient  food  are  exaggerated.  Very  often,  unless  the  palate  is  cleft 
in  addition,  children  with  hare-lip  can  suck  well  and  are  in  good  con- 
dition. When  the  palate  is  also  cleft,  a  serious  difficulty  may  arise 
from  the  food  passing  into  the  nose,  but  this  may  be  usually  met  by 
careful  feeding  with  a  small  spoon  put  well  back,  if  a  sucking-bottle 
with  a  large  teat  fails  (p.  318). 

Where  the  child  really  cannot  get  sufficient  nourishment,  and  is 
marasmic  from  this  cause  and  this  only,  the  surgeon  will  of  course 
operate  at  an  earlier  date  than  three,  or  even  two,  months.  But  a  child 
that  is  daily  wasting  is,  daily,  less  and  less  able  to  meet  the  strain 
entailed  by  the  operation,  and  consequent  repair.  This  should  be 
clearly  understood  by  the  friends,  and  also  the  following  fact : 

2.  It  is  not  uncommon  for  children  with  hare-lip  to  die  soon  after 
birth  from  causes  Avith  which  this  deformity  has  nothing  to  do— viz., 
diarrhoea,  lung-trouble,  exhaustion.  If  an  operation  be  performed 
early  in  such  cases  death  will  be  put  down  to  it,  and  not  to  the 
above  causes,  which  would  have  destroyed  the  child  in  any  case. 

3.  As  stated  by  Mr.  T.  Smith,t  "the  operation  ctin  be  done  much 
more  perfectly  and  artistically  on  a  young  child  than  on  a  new-born 
Infant,  the  parts  being  larger,  more  fleshy,  and  more  easily  handled." 
Sutures  also  cut  out  less  readily. 

4.  For  the  first  few  weeks  of  life  the  child  has  scarcely  got  over  the 
change  from  intra-uterine  to  extra-uterine  life,  the  function  of  digestion 
is  not  yet,  so  to  speak,  in  full  swing,  and  a  very  slight  shock  may  be 
too  much  for  the  low  vitality  of  this  period. 

Condition  of  the  Hare-lip. — Before  operating,  the  following  points  must 
be  inquired  into.  As  in  other  plastic  operations,  one  or  two  careful 
examinations  should  be  made  of  the  parts  before  any  attempt  at 

*  Clin.  Surg.,  Syf.  Soc.  -Trans.,  p.  78. 
t  Lancet,  1867,  vol.  ii.  p.  761. 


HARE-LIP.  305 

uniting  them.  Is  the  cleft  single  or  double?  If  single,  is  it  simple, 
i.e.,  without  involving  the  nose,  and  without  fissure  of  the  palate  ?  Are 
the  sides  equal  and  acute-angled,  or  divergent  and  unequal?  Other 
sources  of  difficulty  are,  much  flattening  of  the  nose  from  the  septum 
being  adherent  and  dragged  over  to  the  superior  maxilla  on  one  side, 
and  the  ala  of  the  opposite  side  being  spread  out  and  stretched  over  the 
upper  part  of  the  fissure.  Or  the  edges  of  the  lip  are  widely  apart,  and 
by  no  means  to  be  approximated,  the  alfe  being  so  widely  separated 
that  lines  let  fall  vertically  through  them  only  come  just  within  the 
angles  of  the  mouth. 

Other  more  general  points  will  of  course  be  remembered  as  influ- 
encing the  result  of  the  operation.  Amongst  these  are,  the  digestive 
and  sleeping  power  of  the  infant;  its  family  history;  the  existence  of 
any  weakening  condition,  such  as  otorrhoea;  and,  by  no  means  least, 
the  good  sense  and  patience  of  the  nurse. 

The  Single  Hare-lip  operation  and  the  one  applicable  to  the 
largest  number  of  cases  will  be  first  described  fully,  and  then  one  or 
two  modifications. 

(i.)  The  Usual  Operation  (Fig.  63). — The  child  being  wrapped 
in  a  long  towel,  mummy-wise,  to  ensure  the  hands  being  secured  if  it 
"  come  to  "  prematurely,  ether  or  chloroform  is  given,  and  the  head  is 
held  suitably  presented  to  the  ojDerator  by  an  assistant  whose  hands, 
at  the  same  time,  make  pressure  upon  the  facial  arteries  as  they  cross 
the  jaw.  The  lips,  and,  if  needful,  the  alse  also,  are  now  freely  sepa- 
rated from  the  subjacent  bones  to  allow  of  their  coming  together  with- 
out tension  ;  during  this  step  the  knife  should  be  kept  very  close  to  the 
bone,  otherwise  the  hasmorrhage  will  be  free.  If  one  maxillary  bone 
project  inconveniently  beyond  its  fellow,  it  must  now  be  forcibly  bent 
back  with  non-serrated  forceps  covered  with  thin  drainage-tube  ar 
wash-leather.  The  bone  should  be  felt  to  crack  when  this  is  done, 
otherwise,  if  merely  bent  back,  it  springs  forward  again  and  causes 

tension  on  the  flaps.     The  edges  of  the  cleft  are  now 

Fig  63  * 
pared.     This,  the  most  important  part  of  the  v/hole  "  , 

operation,  must  be  done  carefully  and  thoroughly  as 

well.     The  surgeon  seizes  the  lower  angle  of  each  flap, 

alternately,  either  with  his  left  forefinger  and  thumb, 

or,  if  the   parts   are   very   small   and   slippery,  with 

tenaculum-forceps   which   should   not  hold   the   soft 

parts  too  near  the  edge,  or  it  will  tear  out  too  soon. 

(Druitt ) 

The  edges  being  thus  made  tense,  the  surgeon  with  a 

narrow  bladed  small  knife  pares  them  as  widely  as  possible  by  two 


*  Simple  hare-lip  with  equilateral  sides.*   To  ensure  as  broad  a  surface  as  possible 
the  incision  should  be  made  rather  farther  from  the  sides  of  the  fissure, 

20 


306  OPERATIONS   ON    THE    HEAD    AND    NECK. 

incisions  beginning  above  at  the  upper  angle  of  the  cleft,  curving  out- 
wards somewhat  as  they  descend,  and  then,  in  the  lower  part,  curving 
inwards  again  through  the  red  prolabium  (Fig.  63).  The  pared  sur- 
faces should  be  made  as  wide  as  possible,  especially  below,  in  order 
that  the  sutures  may  hold  better  and  the  lip  be  deeper.  If  one  mar- 
gin of  the  flap  is  longer  than  the  other,  this  should  be  pared  first,  and 
after  this  its  fellow,  that  both  may  correspond.  During  this  paring, 
haemorrhage  must  be  prevented  either  by  the  assistant  who  compresses 
the  facial  while  he  supports  the  head,  or  by  an  assistant  compressing 
the  coronary  artery,  between  his  finger  and  thumb,  at  the  corner  of 
the  mouth,  or  by  hare-lip  clamps  placed  at  the  corners  of  the  mouth. 

The  assistant  who  steadies  the  head  and  keeps  pressure  on  the  facial 
arteries,  now,  with  two  fingers,  presses  the  cheeks  together,  so  as  to  bring 
the  flaps  into  apposition  while  the  surgeon  introduces  his  sutures.  I 
much  prefer  for  these,  first,  one  of  medium  silver  wire  to  command  the 
coronar}^  arteries  and  passed  close  to  the  mucous  membrane.  If  one 
flap  is  still  sliorter  than  the  other,  this  stitch  may  be  passed  through 
the  opposite  side  from  below  upwards,  then  entered  on  the  shorter  side 
at  a  point  a  little  higher  than  that  at  which  it  left  its  fellow  and  passed 
from  above  downwards  so  as  tilt  down  the  margin  which  is  highest 
and  bring  it  level  with  the  other.  This  first  stitch  being  passed,  and 
the  chief  fear  of  bleeding  removed,  three  or  four  others  of  fishing-gut, 
horsehair,  or  fine  carbolized  silk  are  inserted,  one  being  placed  in  the 
free  margin  of  the  lip  to  keep  the  wound  carefully  closed  here  against 
the  entrance  of  milk,  saliva,  etc.  In  adjusting  the  top  stitch  care  must 
be  taken  that  it  does  not  too  much  depress  the  tip  of  the  nose,  if  the 
cleft  has  been  one  running  up  into  the  nostril.  All  the  chief  stitches 
should  be  inserted  i  inch  from  either  side  of  the  cleft.  They  are  in- 
serted with  very  fine  needles. 

It  will  be  gathered  from  the  above  that  I  do  not  advise  the  use  of 
hare-li})  pins.  They  are  useful  no  doubt  in  promoting  close  and 
accurate  union  where  the  parts  come  together  easily,  but  at  the  expense 
of  the  risk  of  sloughing  and  scars  even  here ;  where  tension  is  con- 
siderable this  risk  is  very  much  increased.  The  surgeon  will,  I  think, 
do  more  wisely  who  adopts  the  sutures  already  described,  j^reventing 
tension  by  freely  separating  the  soft  parts  from  the  bone.  If  pins  are 
used  they  should  be  far  slenderer  than  those  usually  sold,  the  first 
should  be  inserted  low  down  so  as  to  command  the  coronary  arteries, 
and  if  one  side  of  the  cleft  is  shorter  than  its  fellow  the  pin  should  be 
passed,  so  as  to  draw  it  down,  in  the  manner  already  described. 

The  sutures  being  inserted  and  tied,  the  nostrils  are  cleared  of  any 
clots,  some  iodoform  is  dusted  over  the  wound,  a  tiny  bit  of  lint 
smeared  with  eucalyptus  ointment  is  placed  over  the  wound,  some 


HARE-LIP.  307 

collodion  is  i3ainted  on  evenly,  and,  if  any  tension  remains,  one  or 
two  pieces  of  strapping,  cut  narrow  in  the  centre,  are  applied. 

We  still  want  some  instrument  easily  applied  for  hare-lip,  and 
adaptable  in  hospital  practice  to  different-sized  heads.  Hainsby's 
truss,  ingenious  as  it  is,  has  serious  drawbacks.  As  it  is  not  adjust- 
able to  other  heads  than  that  for  which  it  was  made,  the  surgeon  needs 
several  sizes.  It  should  always  be  worn  for  several  days  before  the 
operation,  not  so  much  to  approximate  parts  as  to  prevent  pressure- 
sores,  which  form  extremely  easil}'  and  leave  disfiguring  scars. 

To  support  the  flaps  and  keep  them  in  place,  M.  Louis's  bandage 
may  be  made  use  of.  It  is  thus  described  by  Mr.  Mason  ;*  A  double- 
headed  roller,  about  an  inch  wide  and  a  yard  and  a  half  long,  is  placed 
with  its  centre  over  the  middle  of  the  forehead,  and  the  two  ends  are 
then  carried  behind  the  head  over  the  ears  to  the  occiput,  where  they 
are  made  to  cross,  and  brought  forward  again.  Two  slits  are  now 
made  in  one  end,  and  the  other  end  slit  into  two.  The  two  ends  are 
then  passed  through  the  two  slits,  and  then  by  making  traction  on  the 
ends  the  edges  of  the  lip  are  brought  together.  The  ends  are  carried 
back  again  to  the  nape  and  there  fastened. 

In  the  after-treatment,  the  wound  may  be  looked  at  on  the  second 
or  third  day,  the  silver  wire  removed  on  the  fourth  day,  and  the  others 
left  in  much  longer.  A  camel's-hair  brush  is  the  best  Avay  of  cleansing 
the  wound.  On  each  occasion  the  cheeks  must  be  most  carefully  sup- 
ported. 

There  is  one  point  of  great  importance  which  is  not  alluded  to  in 
surgical  works,  and  that  is,  that  in  some  cases  of  hare-lip  death  from 
dyspnoea  may  take  place  very  soon  after  the  operation.  Thus,  where 
the  cleft  has  been  a  large  one,  and  the  upper  lip  when  restored  is  tight, 
when  it  overhangs  the  lower,  if  the  nostrils  are  flattened  and  partially 
closed  by  the  operation,  owing  to  the  tension  of  the  parts,  so  little 
breathing  space  may  be  left  that  temporary  interference  with  respira- 
tion may  occur,  with  grave  and  even  fatal  results  before  the  breathing 
can  be  accommodated  to  the  altered  circumstances,  and  before  the 
parts  dilate  and  stretch. 

The  first  case  that  drew  my  attention  to  this  accident  occurred  in 
the  early  part  of  1887  at  Guy's  Hospital.  I  had  operated  on  an 
infant,  aged  three  months,  with  a  large  cleft  with  unequal  sides,  and 
going  through  the  alveolar  margin,  the  two  halves  of  these  being  on 
different  levels.  The  projecting  alveolus  was  broken  back  into  posi- 
tion, pared,  and  stitched  with  chromic  catgut  to  its  fellow.  The  edge& 
of  the  cleft  w^ere  then  pared  and  united.  They  came  together  excel- 
lently, the  wide  cleft  being  rej^laced  by  a  deep  upper  lip.  One  nostril 
was  rather  chink-like.    About  half  an  hour  after,  whilst  I  was  engaged 

*  St.  Thomas's  Hosp.  Eepn.,  vol.  vi.  p.  160. 


^508  OPERATIONS    ON    THE    HEAD    AND    NECK. 

in  another  operation,  a  message  came  that  the  child  was  livid  and 
dying.  I  had  the  child  at  once  brought  to  me  in  the  theatre,  the 
strapping  was  removed,  the  tongue  carefully  drawn  forward,  and  arti- 
ficial respiration  performed.  The  child  quickly  came  to  and  began 
to  cr}',  though  not  very  vigorously.  Three-quarters  of  an  hour  later 
its  breathing  again  failed,  and  though  Mr.  Wacher,  at  that  time  senior 
house-surgeon,  at  once  repeated  the  artificial  respiration,  we  were  un- 
able to  resuscitate  the  child.  At  the  post-mortem  examination  no 
clot  was  found  in  the  fauces,  nor  anything  else  wrong.* 

Hunting  about  to  see  if  others  had  met  with  this  untoward  result, 
I  found  that  my  old  friend,  (}.  A.  Wright,t  of  Manchester,  had 
recorded  two  cases  of  a  like  nature.  The  children  here  were  aged 
three  and  five  weeks  respectively,  the  hare-lips  double ;  in  one  it  was 
noticed  that  after  the  operation  the  lower  lip  was  drawn  in  so  much 
as  to  leave  but  a  small  opening,  but  there  was  not  apparently  any 
dyspnoea.  In  one  case  d3^spncea  came  on  suddenly,  and,  as  no  relief 
followed  on  pulling  the  tongue  out,  tracheotomy  and  artificial  respi- 
ration were  performed.  The  child  came  round,  but  a  few  hours  later 
the  breathing  failed  again,  and  the  child  died.  In  the  second  case,  the 
child  was  found  dead  in  the  night.  "  The  cause  of  death  was  prob- 
ably valve-action  of  the  lower  lip." 

In  cases  of  hare-lip  where  the  divergence  is  great,  and  where  the 
sides  of  the  cleft  are  very  unequal,  the  following  operations  may  be 
made  use  of,  but  it  will  be  found  that,  on  the  whole,  the  first-mentioned 
is  not  only  the  quickest  performed,  but  also  gives  the  best  results 
wherever,  by  free  separation  from  the  jaws  and  broad  paring  of  the 
edges,  the  flaps  can  be  adjusted  together. 

(ii.)  Operation  of  Clemot  I  or  Malgaigne  (Figs.  64,  65). — The 
edges  are  pared  down  to,  but  not  beyond,  the  red  lines,  the  flaps  thus 
detached  above  are  turned  downwards  and  kept  in  this  position  out  of 
the  cleft  with  a  probe.  The  upper  part  of  the  cleft  is  then  sewn  together 
with  the  sutures  already  advised,  while  the  projecting  tongue  is 
shortened  as  required  with  a  pair  of  sharp  scissors  and  united  with  one 

*  I  think  that  I  ought  to  mention  that  Louis's  bandage  was  applied  in  this  case. 
The  mouth  was  quite  free,  but  the  effect  of  the  bandage  must  have  been  to  increase  the 
diminution  of  the  aperture,  and  to  maintain  the  altered  condition  of  parts,  which  was 
very  considerable. 

f  Abstracts  of  Cases  Treated  at  the  Pendlebury  Hospital,  1885,  p.  146.  In  his  Abstracts 
for  1883  Mr.  Wright  records  a  case  in  which,  after  operation  for  hare-lip,  there  was  so 
much  dyspnoea,  from  the  tongue  clinging  to  the  roof  of  the  mouth  at  each  inspiration, 
"  that  it  had  to  be  pulled  out  and  fastened  by  a  ligature." 

X  M.  N^laton  {Pathol.  Chirurg.,  t.  iv.  p.  496)  states  that  M.  Malgaigne  here  imitated 
M.  Clemot,  of  Rochfort. 


HARE-LIP.  309 


or  two  points  of  horsehair.     The  chief  objection  to  this  method  is,  that, 
unless  great  care  is  taken,  a  little  skin,  imperceptible  at  first,  but 


Fig.  65. 


I  (Nelaton.)  (Nelatou.) 

showing  white  after  a  time,  may  remain  below  the  red  line,  or  as  a 
break  in  it. 

Where  the  divergence  is  more  marked  and  the  sides  of  the  cleft 
very  unequal,  the  following  may  be  made  use  of: 

(iii.)  Method  of  Mirault  (Figs.  66,  67).— On  the  side  which  is 
the  most  vertical  of  the  two  an  incision  is  to  be  made  downwards  and 
outwards  from  the  apex  of  the  cleft  to  the  junction  of  skin  and  mucous 
membrane,  so  as  to  leave  a  flap  on  this  side  free  above,  but  attached 
below.     The  other  more  sloping  side  is  then  freely  pared  throughout 

Fig.  66.*  Fig.  67. 


(N<51aton.)  (Nelaton.) 

its  extent  from  the  apex  downwards  and  outwards.  Any  adhesions 
of  the  lips  to  the  gums  being  then  thoroughly  separated,  the  flap  is 
brought  across  and  attached  to  the  pared  opposite  side  with  the  sutures 
already  mentioned. 

If  this  method  be  made  use  of  the  flap  must  not  be  a  mere  paring, 
but  cut  as  thick  and  succulent  as  possible,  and  the  opposite  side  must 
be  thorouglily  and  widely  refreshed. 

(iv.)  Method  of  Nelaton  (Figs.  68,  69).— This  gives  another 
means   of  substituting   a   protuberance   for  the   cleft.     An   incision 


*  The  sides,  especially  the  one  which  is  refreshed  throughout  its  whole  extent, 
should  be  pared  as  in  Fig.  67— that  is,  somewhat  angularly — so  as  to  promote  the 
adjustment  of  the  flaps,  as  it  were  by  interlocking. 


310  OPERATIONS    ON    THE    HEAD    AND    NECK. 

resembling  a  v  reversed  is  made  around  the  upper  angle  of  the  cleft. 
By  this  means  the  red  edge  of  the  cleft  is  separated  from  the  two 
halves  of  the  lip,  except  at  each  corner  below.     This  red  edge  is  next 

Fig.  08.  Fig.  69. 


(N^latou.)  iN<51aton.) 

turned  downwards,  or  reversed  so  that  the  A -shaped  wound  becomes 
diamond-shaped.  The  bleeding  surfaces  are  then  brought  together 
by  the  means  already  given. 

Mr.  Holmes*  considers  that  Nelaton's  operation  is  peculiarly 
adapted  to  clefts  which  do  not  extend  through  the  whole  depth  of  the 
lip,  but  terminate  at  some  distance  from  the  nostril.  These  instances 
are  rare,  but  Mr.  Holmes  further  points  out  that  in  cases  where  an 
unsightly  notch  is  left  behind,  if  there  be  not  much  cicatrization 
around  the  incision,  the  deformity  may  be  almost  certainly  remedied 
by  this  operation. 

DOUBLE  HARE-LIP  (Figs.  70,  71). 

This  is  often  easier  of  cure  than  single  hare-lip  with  very  divergent 
sides  and  the  alveolar  margin  cleft  and  its  two  parts  on  unequal  levels. 
For  in  double  hare-lip  the  mischief  is  symmetrical,  and  the  sides  less 
divergent. 

Mr.  T.  Smith  (loc.  supra  cit.,  p.  799)  gives  the  three  following  vari- 
eties of  hare-lip  which  are  met  with  here  and  which  are  of  practical 
importance : 

(a)  When  the  pre-maxillary  bone  is  in  situ,  and  the  two  clefts  are 

simple  and  fairly  bilateral. 
(/?)  When  the  pre-maxillary  bone  is  separated  from  the  rest  of 
the  jaw  and  projects  forwards,  in  some  cases  slightly,  in 
others  being  attached  to  the  vomer  and  hanging  from  the 
tip  of  the  nose. 
(y)  When  the  pre-maxillary  bone  is  small  and  ill-developed,  and 
when  the  clefts  are  widely  gaping, 
(a)  If  the  pre-maxillary  bone  is  in  proper  position,  the  skin  over  it 
is  freed  from  its  attachments  Vjehind  and  pared  to  a  point.     The  sides 

*  Surg.  Dis.  of  Children,  p.  104. 


HARE-LIP.  311 

of  the  cleft  are  next  pared  from  above  downwards  (as  in  Fig.  63),  and 
the  parts  brought  together  by  transfixing  the  sides  and  the  central 
flap  with  a  silver  wire  suture,  every  care  being  taken  to  keep  the  cen- 
tral piece  well  down.  Horsehair  and  gut  sutures  are  also  used  as 
well.  As  the  central  piece  is  always  shorter  than  the  lii?  itself,  the 
resulting  wound  is  Y-shaped,  and  it  is  the  side  flaps  which  meet  each 
other  in  the  middle  line  below.  Care  must  be  taken  to  free  the  central 
flap  right  up  to  the  nose,  and  not  to  depress  it  too  much  with  the 
sutures,  otherwise  the  nose  will  be  flattened. 

G?)  Cases  in  which  the  pre-maxillary  bone  is  sej^arated  from  the 
maxillse,  projecting  forwards,  sometimes  being  even  attached  to  the 
very  tip  of  the  nose. 

The  question  of  removing  or  leaving  the  pre-maxillary  bone  arises 
here,  and  the  very  best  authorities  have  diff'ered  widely.  On  the  one 
hand.  Sir  W.  Fergusson,  writing  as  late  as  1874,*  advised  its  removal, 

Fig.  71.t 


Fig.  70. 


(N61aton.) 


(Holmes.) 

if  it  projected  much,  as  pressing  it  back  was  difficult  and  unsatis- 
factory, as  the  teeth  in  it  could  not  be  relied  upon  to  come  through 
usefully,  as,  if  a  cleft  palate  was  present,  the  gap  narrows  better  after 
the  removal  of  the  bone,  and  a  dentist  can  fit  a  plate  that  will  answer 
the  purpose  quite  as  well.  On  the  other  side,  Mr.  Holmes  X  argues 
thus  :  "  It  is  of  the  highest  importance  to  preserve,  if  possible,  this 
portion  of  bone,  for  three  reasons  :  (1)  If  the  bone  be  removed,  there 
must    be    a    permanent   gap  through    the   hard   palate.     (2)  There 

*  Brit.  Med.  Journ.,  vol.  i.  1874,  p.  403. 

f  From  Mr.  Holmes's  book,  quoted  above,  Fig.  21. 

J  Surg.  Dis.  of  Children,  p.  108. 


312  OPERATIONS    ON    THE    HEAD    AND    NECK. 

must  also  be  a  flattening  and  malposition  of  the  upper  lip,  in  con- 
sequence of  its  having  lost  its  bony  support ;  and  from  this  flattening 
of  the  upper  jaw  it  will  result  that  the  lip  will  be  very  short  and 
tense,  and  the  patient  extremely  '  underhung,'  a  very  unpleasing 
deformity"  (Fig.  71).  While  no  doubt  the  hands  of  Sir  W.  Fer- 
gusson,  with  his  great  operative  experience,  were  able  to  secure 
good  results  after  removal  of  this  bone,  most  surgeons  will  prefer 
to  follow  Mr.  Holmes's  advice.  Mr.  Holmes,  a  little  later,*  goes  on 
to  say  that  in  a  few  cases  it  may  be  necessary  to  sacrifice  the  bone, 
e.(/.,  where  it  is  very  far  forward,  very  much  out  of  proportion  to 
the  neighboring  parts,  and  the  child  very  weak. 

I  am  of  opinion  that,  if  the  following  points  be  attended  to,  the 
pre-maxillary  bone,  however  advanced  and  firmly  based,  can  be 
replaced  and  preserved ;  weakness  on  the  part  of  the  child,  which 
is  undoubtedly  a  matter  of  grave  consideration  in  cases  like  this, 
where  the  loss  of  blood  is  considerable,  is  best  met  by  doing  the 
operation  by  two  stages — in  other  words,  being  content  to  first  get 
this  bone  replaced,  and  leaving  the  uniting  of  the  soft  parts  till 
another  time. 

Where  the  stalk  of  attachment  of  the  pre-maxillary  bone  is  slender, 
and  where  there  is  plenty  of  room  between  the  two  maxillse,  it 
may  be  often  broken  back  into  place  by  the  operator  supporting  with 
his  left  hand  the  back  of  the  child's  head  and  then  wdth  his  right 
thumb  sharply  fracturing  back  the  bone.  This  should  be  done 
thoroughly,  and,  if  needful,  by  the  aid  of  non-serrated  forceps  cov- 
ered with  drainage-tube,  or  bone-forceps  may  be  applied  to  the  stalk 
in  front  and  also  behind  till  it  is  almost  completely  cut  through.  If 
now  it  can  be  replaced,  but  tends  to  come  forward  again,  it  should  be 
sutured,  on  one  side  at  least,  to  the  maxilla?  with  chromic  catgut  or 
carbolized  silk,  or  wire. 

If  the  maxillary  bones  on  one  side  or  both  are  in  the  way,  and 
prevent  the  replacing  of  the  pre-maxillary  bone  after  it  has  been  de- 
tached sufficiently,  or  if  this  is  too  voluminous,  its  sides  must  be  cut 
away  and  the  maxillae  also  pared  till  the  central  piece  can  be  pushed 
back  between  them  and  retained  with  the  suture,  as  above  advised. 

A  severer  method,  one,  therefore,  which  should  only  be  tried  when 
all  other  means  of  replacing  the  pre-maxillary  bone  have  failed,  is  to 
cut  a  wedge-shaped  gap  out  of  the  septum  nasi  and  to  press  or  fract- 
ure the  partially  detached  bone  into  the  gap.  Some  have  passed  a 
suture  t  through  the  septum  before  the  wedge  is  cut  out  and  then 
united  the  ends  over  the  pre-maxillary  bone  to  keep  it  in  place. 

*  Loc.  supra  cit.,  p.  109. 

f  If  he  do  this  the  surgeon  must  be  provided  with  needles  of  different  curves. 
Small  curved  ones  in  a  holder  offer  more  variety  than  those  in  handles. 


HAEE-LIP.  313 

The  htpmorrhage  may  be  very  free  in  these  cases  where  very  vascu- 
lar bones  are  cut  throug'h.  I  have  generally  found  that  it  is  at  once 
arrested  by  suturing  the  bones,  but  in  some  cases  it  may  be  needful 
to  apply  a  fine  point  of  actual  cautery  or  of  the  thermo-cautere ;  if 
this  has  been  necessary,  or  if  the  child  is  very  weakly,  the  uniting  of 
the  soft  parts  had  better  be  left  to  another  time. 

It  is  absolutely  necessary,  by  some  means  or  other,  to  get  the  pre- 
maxillary  bone  quite  back  and  to  make  it  stay  there,  as  otherwise 
the  soft  parts  over  the  projecting  bone,  or  the  line  of  union  which 
often  comes  just  opposite  to  it,  will  be  pressed  upon  and  give  way. 

So  where  the  surgeon  is  unable  to  get  the  bone  back  by  any  method 
he  may  follow  the  advice  of  Sir  W.  Fergusson,  *  and  incising  the 
mucous  membrane  over  the  bone,  separate  this  sufficiently  to  intro- 
duce a  small  gouge  about  4  inch  broad,  scoop  out  the  temporary 
incisors,  and  cut  away  the  wall  of  bone,  which  for  the  first  eight  weeks 
consists  of  merely  a  few  plates.  By  this  the  projection  is  removed, 
and  the  tissues  which  remain  offer  no  obstruction  to  the  union  of  the 
lip  in  front.  Only  the  mucous  membrane  and  some  periosteum  are 
left  to  form  a  soft  cushion  behind  tlie  united  lip.f  Furthermore,  by 
this  means  any  spirt  of  blood  is  avoided. 

Mortality  after  Operations  for  Hare-lip. — Facts  appear,  as 
yet,  to  be  wanting  to  decide  whether  it  is  the  malformation  itself  or 
the  operation  which  influences  the  mortality.  German  surgeons  have, 
with  their  usual  painstakingness,  collected  statistics  bearing  on  this 
subject. 

Dr.  Hotfa,!  of  Wiirzburg,  considers  that  the  malformation,  Dr. 
Gotthelf,§  of  Heidelberg,  that  it  is  the  operation,  which  has  the  inju- 
rious effect.  However  this  may  be,  it  seems  to  be  clear  that  the 
mortality  is  much  higher  with  them  than  with  us.  Thus,  of  134 
cases,  the  total  mortality  amounted,  for  the  first  three  months,  to  23.4 
per  cent.  Again,  of  121  cases  operated  on  by  Billroth,  Rose,  and 
Czerny,  41  or  34.1  per  cent,  died  within  a  year.  Of  course  the  cause 
of  death  in  these  cases  cannot  be  entirely  attributed  to  the  operation. 
The  fact  that  primary  union  followed  in  about  half  of  Czerny's  cases 
of  hare-lip  seems  to  support  strongly  the  view  that  it  is  the  weakness 
of  the  infant  which  influences  the  mortality. 

Repetition  of  Operation. — I  cannot  leave  this  subject  without 
reminding  my  younger  readers  that  in  many  cases  a  perfect  result  can- 
not be  secured  by  one  operation.  Where  parents  are  likely  to  be 
unreasoning  and  unreasonable,  the  surgeon  should  warn  them  of  this. 

*  Brit.  Med.  Journ.,  loc.  supra  cit. 

t  This  cushion  can  be  stitclied  to  the  maxillifi,  if  needful. 

J  An-nals  of  Surgery,  January,  1887. 

^  76k/.,  January,  1886. 


314  OPERATIONS   ON    THE    HEAD    AND    NECK. 

In  cases  unfavorable,  owing  to  the  malformation,  or  the  general 
condition,  and  already  alluded  to  (p.  304),  hare-lips,  which  have  been 
operated  on,  often  cause  disappointment,  however  much  they  resemble 
jiictures  in  books  up  to  the  third  day.  Incomplete  closure,  below  or 
above,  a  little  inequality  in  the  level  of  the  halves  of  the  new  lip,  some 
flattening  and  closure  of  the  nostrils,  any  of  these  may  mar  the  first 
operation.  The  more  operations  a  surgeon  does  the  more  difficult 
and  trying  cases  will  he  meet  with.  He  can  scarcely  do  better  than 
remember  the  words  of  the  great  surgeon  of  Vienna  :  *  "  Operations 
on  little  children  do  not  always  succeed  as  well  as  could  be  wished, 
on  account  of  the  diminutive  size  and  softness  of  the  parts.  The  flaps 
of  the  lips  cannot  always  be  adapted  as  exactly  as  desired,  and  even 
if  this  be  satisfactorily  accomplished,  the  result  does  not  in  every  case 
quite  come  up  to  expectation,  so  that,  some  few  years  after,  further 
slight  proceedings  become  desirable,  in  order  to  improve  the  appear- 
ance." And,  again,  a  little  later,  the  same  surgeon,  speaking  of 
operations  on  "  quite  little  children,"  says:  "I  decline  to  give  any 
absolute  guarantee  with  regard  to  the  result  in  such  cases." 

OTHER  PLASTIC  OPERATIONS  ON  THE  LIPS 

(Figs.  72-75). 

These  are  very  numerous,  especially  for  the  restoration  of  the  lower 
lip  after  ulcerations,  epitheliomatous,  etc.,  injuries  and  burns.  A  few 
of  the  chief  will  be  described  here. 

The  chief  objects  which  the  surgeon  must  keep  before  him  are  :  (1) 
to  get  sufficient  flaps  of  healthy  tissue,  consisting  of  skin  outside  and 
mucous  membrane  within,  and  to  secure  as  free  a  margin  as  possible 
of  this  last ;  (2)  to  keep  the  flaps  together  with  as  little  tension  as  pos- 
sible ;  (3)  to  cover  in  the  teeth  sufficiently,  preserving  the  mouth 
opening  of  appropriate  size. 

Lower  Lip. 

(i.)  Method  of  Serre  (Fig.  72). — Where  a  growth  implicates  the 
whole  of  the  lower  lip,  but  does  not  extend  far  down  upon  the  chin, 
this  operation  gives  excellent  results.  If  the  angles  of  the  mouth  are 
also  involved,  the  operation  consists  practically  in  removing  three 
triangular  portions  of  soft  parts,  as  shown  in  the  dotted  lines  in  Fig. 
72,  Two  of  these  have  their  apices  on  the  cheeks,  and  their  bases  at 
the  angles  of  the  mouth,  while  the  central  triangle  has  its  apex  down- 
wards towards  the  chin,  and  its  base  turned  upwards  to  the  mouth. 

If  the  angles  are  not  involved,  straight  incisions,  and  not  triangular 
ones,  may  be  made  out  on  to  the  cheeks,  while,  if  needful,  the  apex 

*  Billroth,  Clin.  Surg.,  p.  79. 


EESTORATION   OF    LIPS. 


315 


of  the  central  can  be  carried  down  on  to  the  chin  or  even  on  to  the 
neck,  some  further  incisions  being  usually  required  in  such  a  case — 
viz.,  curving  outwards  laterally  from  the  apex  along  the  jaw  or  in  the 
submaxillar}''  region,  as  in  Fig.  72.  The  flaps  are  united  with  silver 
wire,  salmon-gut,  and  horsehair  ;  a  few  fine  hare-lip  pins  being  used, 
if  needful,  to  overcome  tension.  The  sutures  should  be  put  in  suffi- 
ciently close  to  distribute  any  tension  evenly,  and  the  chief  ones 
should  be  one-third  of  an  inch  from  the  edges  of  the  wound,  and 
should  be  passed  close  to  the  mucous  membrane.  As  far  as  practi- 
cable, bleeding  points  should  be  commanded  by  sutures,  and  torsion  or 
ligatures  dispensed  with  as  far  as  possible.  Any  pins  used  should  be 
removed  on  the  second  or  third  day  and  the  sutures  one  or  two  at  a 
time.     Iodoform  and  collodion  is  as  good  an  application  as  any. 

(ii.)  Method  of  Syme'^  (Fig.  72). — The  principle  of  this  opera- 
tion is  to  leave  the  central  and  prominent  part  of  the  chin  undis- 
turbed, two  lateral  flaps  supplying  the  defect. 

Supposing  the  whole  lower  lip  aff"ected,  the  growth  is  removed  by 
two  incisions  passing  from  the  angles  of  the  mouth  to  the  prominence 


Fig.  72. 


Fig.  73.t 


The  dotted  lines  show  the  operation  of 
Serre,  the  continuous  ones  that  of  Syme.  The 
central  part  of  each  runs  too  near  to  the 
growth. 


The  quadrangular  incisions  on  the 
chin  will  indicate  the  method  of  Chop- 
art.  The  triangular  incisions  show  how 
a  growth  at  the  corner  of  the  mouth 
may  be  dealt  with.    (After  Serre.) 


of  the  chin.  Bleeding-points  being  compressed  by  assistants,  the  sur- 
geon makes  two  incisions  from  the  apex  of  his  first,  passing  at  first 
straight  downwards  and  outwards,  and  then  curving  outwards  and 
upwards,  so  as  to  free  two  large  lateral  flaps,  which  are  dissected  up 


*  Observ.  in  Clin.  Surg.,  p.  60. 

f  This  and  the  next  two  figures  are  taken  from  M.  Serre's  atlas  accompanying  his 
Traitesur  I'ai-tde  resiaurer  les  Diffonnites  de  la  Face,  selon  la  melhode  par  deplacement. 
Montpellier:  1842, 


3i6  OPERATIONS    ON   THE    HEAD    AND    NECK. 

as  thick  as  possible  and  united  in  the  manner  already  described.  The 
first  part  of  the  two  lateral  incisions — viz.,  those  passing  downwards 
and  outwards,  meet  in  the  middle  line  to  form  the  new  lip.  This  is 
supported  by  the  prominence  of  the  chin,  which  retains  its  natural 
connections.  The  lower  and  more  curved  parts  of  the  incision  must 
be  carried  outwards  as  far  as  necessary  to  the  angles  of  the  jaw  in 
order  to  allow  the  flaps  to  come  into  position  readily,  and  without 
tension,  and  without  leaving  gaps  to  granulate. 

(iii.)  Method  of  Buchanan. — This  is  planned  on  the  same  lines 
as  that  of  Prof.  Syme.  The  growth  is  removed,  here,  by  an  elliiDtical 
incision.  From  the  centre  of  this  two  incisions  are  made,  first  down- 
wards and  a  little  outwards,  and  then  from  the  ends  of  these  two 
curving  outwards  and  upwards,  much  as  in  Prof.  Syme's  operation. 
When  flaps  thus  marked  out  are  detached  and  raised,  the  elliptical 
incision  becomes  horizontal  and  forms  the  new  lower  lip. 

Both  in  this  and  Prof.  Syme's  operation,  when  the  gap  is  very  large 
or  the  soft  parts  scanty,  two  small  triangular  gaps  may  be  left  below. 
The  healing  of  these  will  take  place  by  granulation,  and  should  be 
promoted  by  skin-grafting. 

(iv.)  Method  of  Chopart. — Here  the  growth  is  removed  by  a 
quadrangular  incision,  the  upper  margin  being  formed  by  the  lip,  the 
lower  by  an  incision  parallel  with  it  across  the  chin,  and  at  the 
sides  by  two  vertical  lines  dropping  down  over  and  below  the  jaw.  A 
square-shaped  flap  is  then  dissected  up  from  below,  and  brought  up 
to  form  the  lower  lip.  The  objection  to  this  is  that,  in  spite  of  keep- 
ing the  head  flexed,  the  flap  tends  to  sink  down.  This  tendency 
might  be,  in  part,  prevented  by  freeing  the  flap  more  completely  by 
carrying  out  into  the  sub-maxillary  regions  lateral  incisions  curving 
outwards  and  upwards  from  the  ends  of  the  vertical  ones. 

Upper  Lip. 

(i.)  Operation  of  Sedillot  by  Vertical  Flaps  (Fig.  74).— Flaps 
quadrangular  in  shape  are  raised  by  the  following  incisions  :  (1)  the 
internal  one,  starting  from  a  point  midway  between  the  angle  of  the 
mouth  and  the  lower  eyelid,  and  ending  usually  at  a  point  on  a  level 
with  the  prominence  of  the  chin ;  (2)  a  horizontal  one  passing  out- 
wards from  the  lower  end  of  the  first  for  2  to  2  inches ;  and  (3)  a  sec- 
ond vertical  incision  passing  upwards  from  the  outer  end  of  the  hori- 
zontal one  to  a  point  on  a  level  with  the  ala  of  the  nose. 

These  flaps,  comprising  the  whole  thickness  of  the  cheeks,  are 
moved  inwards  so  that  their  lower  extremities  meet  vertically  in  the 
middle  line. 

(ii.)  Operation  of  DiefiFenbach  and  Chauvel  by  Vertical 
Flaps. — Here  the  flaps  are  cut  in  the  reverse  direction  to  that  of  Sedillot. 
This  method  is  to  be  preferred  in  one  respect,  as,  owing  to  the  base 


CLEFT    PALATE. 


317 


being  below,  there  is  less  tendency  for  the  new  lip  to  be  raised  by  the 
contraction  of  the  scar,  and  thus  to  expose  the  upper  teeth. 

(iii.)  Operation  by  Lateral  Flaps. — Here  the  flaps  are  taken 
laterally  from  the  cheeks.     They  should  be  cut  off  the  full  depth  of 

Fig.  74.  Fig  75. 


The  'dotted  lines  show  the  operation  of 
S^dillot,  the  continuous  ones  that  of  DiefFen- 
bach.for  making  a  new  upper  lip.  (After 
Serre.) 


(After   Serre.) 


the  new  lip,  and  at  their  outer  extremities  should  curve  downwards  so 
as  to  diminish  the  tension.*  Their  inner  extremities  are  united  in  the 
middle  line  below  the  nose. 

(iv.)  Operation  for  Restoring  the  Angle  of  the  Mouth.— 
Fig.  75  shows  the  steps  which  would  be  adapted  for  restoring  the  right 
angle  of  the  mouth  which  has  been  distorted  by  cicatricial  contrac- 
tion :  the  same  proceeding  being  available  for  a  growth  situated  here. 


CHAPTER  IX. 

OPERATIONS  ON  THE  PALATE. 

OPERATIONS  FOR  CLEFT  PALATE— REMOVAL  OF 
GROWTHS  OF  THE  PALATE. 

OPERATIONS  FOR  CLEFT  PALATE  (Figs.  76,  77). 

Age  for  Operation. — If  the  general  health  be  good,t  the  temper 
fairly  sweet,  and  the  cleft  liot  a  very  wide  one,  the  first  attempt  to 

*  Dr.  Port,  of  New  York,  who  figures  this  operation  and  numerous  other  methods 
from  Szymanowski  {Hnnclb.  d.  Chir.  Med.  Braunschweig :  1870),  lays  stress  upon  this 
precaution  {Inter.  Encyc.  Surg.,  vol.  v.  p.  489). 

t  The  difficulty  of  feeding  these  cases  is  often  put  forward  by  the  friends  as  a  reason 
for  an  early  operation.     Cases  are  extremely  rare  in  which  sufficient  food  cannot  be 


318  OPERATIONS    ON    THE    HEAD    AND    NECK. 

close  the  gap  may  be  made  any  time  after  three-and-a-half  or  four 
years.  If  any  further  operation  is  required  it  should  be  performed  in 
the  fifth  or  sixth  year,  and  an}^  case,  however  difficult,  should  be 
completed,  if  possible,  by  the  ninth  or  tenth  year.  As  a  rule,  the 
healthier  the  child  and  the  smaller  the  cleft,  the  earlier  may  the  oper- 
ation be  tried. 

Operations  have  no  doubt  been  performed  during  the  first  year  of 
life,  but  the  risk  of  failure  is  great  owing  to  the  eff'ects  of  haemorrhage, 
the  readiness  with  which  convulsions  are  excited,  the  delicacy  and 
proneness  to  tear  of  the  soft  parts,  while,  as  has  been  pointed  out  by 
Mr.  T.  Smith,  during  the  first  three  or  four  years,  clefts  of  the  bony 
palate  generally  diminish  much  in  width. 

Severity  of  the  Case  and  Kind  of  Patient. — It  is  not  so  much  the  ex- 
tent of  the  fissure — whether  the  soft  palate  is  alone  affected,  partially 
or  completely,  whether  that  common  form,  in  which  the  cleft  involves 
the  soft  and  a  portion  of  the  hard  is  present,  or  whether  the  whole 
palate  is  split — that  is  of  importance,  as  the  width  of  the  cleft  and 
the  thickness  of  the  tissues  which  bound  it.  Sir  W.  Fergusson  was,  I 
believe,  the  first  who  pointed  out  the  influence  which  the  height  of 
the  vault  of  the  hard  palate  has  upon  an  operation  for  closing  a  cleft 
of  it.  He  showed  that  the  higher  the  vault  the  more  easy  was  it  to 
dissect  down  flaps  of  muco-periosteum,  while,  on  the  other  hand,  the 
less  arched  the  vault,  the  greater  was  the  difficulty  in  getting  suffi- 
cient flap.  Other  points  of  importance  are  the  size  of  the  mouth,  a 
very  narrow  or  small  one  interfering  with  the  use  of  the  needful  in- 
struments ;  and  finally,  a  point  always  to  be  noted,  the  length  of  the 
palate,  for  the  shorter  this  is,  the  more  impossible  will  it  be  for  this  to 
touch  the  pharynx  later  on,  however  perfectly  it  has  been  united,  and 
the  more  marked,  consequently,  will  be  the  nasal  tone  of  the  voice. 

Other  points  of  importance,  but  not  connected  especially  with  the 
cleft,  are,  some  which  bear  upon  the  general  health  of  the  patient — 
viz.,  fretfulness  or  a  sunny  temper,  greediness,  as  likely  to  cause  bolt- 
ing of  surreptitious  food,  coexisting  ear  disease,  or  congenital  syph- 
ilis; whether  the  child  has  had  the  usual  illnesses  and  exanthemata; 
an  attack  of  whooping  cough,  scarlet  fever,  mumps,  or  measles  inter- 
fering much  with  the  result  of  an  oj^eration. 

Amount  to  be  Closed  at  One  Sitting,  and   Order  of  Operation. — Where 

given  by  one  of  the  following  methods  (especially  after  any  coexisting  hare  lip  has 
been  closed),  if  only  sufficient  pains  are  persevered  with — viz.,  a  small  spoon  passed 
well  back  into  the  mouth  ;  a  feeding-bottle  with  a  teat  big  enough  to  fill  the  gap,  the 
teat  being  perforated  underneath  for  the  escape  of  the  milk ;  an  ordinary  feeding- 
bottle,  with  a  leaf-like  piece  of  india-rubber  attached  above  the  teat,  so  as  to  fill  up 
the  gap  (as  advised  by  Mr.  Coles);  finally  sometimes  deglutition  will  be  fiicilitated  if 
the  nurse  closes  the  nostrils  with  her  finger  and  thumb  every  time  the  child  swallows. 


CLEFT   PALATE.  319 

the  cleft  involves  both  palates,  that  through  the  soft  is  usually  taken 
first,  the  severer  operation  being  left  till  later.  As  to  the  amount 
which  should  be  attempted  at  the  first  sitting,  each  case  must  be  de- 
cided by  itself,  according  to  the  experience  of  the  operator,  the  severity 
of  the  case,  and  the  safety  with  which  the  anaesthetic  is  taken.  Mr. 
T.  Smith,  the  highest  authority  we  have  on  this  subject,  recommends* 
that  the  whole  cleft  should  be  closed  at  one  sitting,  "unless  there  are 
circumstances  of  peculiar  difficulty  in  the  case.  When  the  bringing 
together  of  the  whole  cleft  in  one  operation  would  necessitate  so  free 
a  division  of  the  soft  ]:»arts  as  to  endanger  the  vitality  of  the  flaps,  it 
is  advisable  to  close  first  that  part  of  the  cleft  that  can  be  most  easily 
approximated,  whether  it  be  the  hard  or  the  soft  palate." 

Had  it  not  been  for  this  opinion  of  Mr.  Smith's,  I  should  have  un- 
hesitatingly advised  the  surgeon  in  his  earlier  operations  only  to 
attempt  to  close  those  parts  which  come  readily  together.  Any  more 
that  can  be  closed  will  only  be  so  at  the  exj)ense  of  a  good  deal  of 
tension,  and  after  much  difficulty  and  a  varying  degree  of  bruising,  etc. 

Operation  on  tlie  Soft  Palate.— The  instruments  which  would 
be  required  for  closing  a  complete  cleft  of  the  palate  may  be  enumer- 
ated here  once  for  all.  One  sharj)  and  one  blunt-pointed  knife  (like 
a  large  tenotomy  knife  on  a  long  handle),  one  pair  of  dissecting-for- 
ceps,  and  one  with  fine  tenaculum  or  mouse-tooth  ends,  at  least  four 
rectangular  needles  with  eyes  at  the  point,  or,  better,  a  supply  of  small 
needles  of  difierent  curves,  to  be  used  with  a  holder,  a  stout  aneurism 
needle,  four  raspatories  of  varying  curve  and  strength,  a  pair  of  curved 
scissors  (with  a  i-inch  curve)  for  detaching  the  soft  palate  from  the 
hard,  one  of  Mr.  Smith's  gags,  which  has  previously  been  found  to  fit 
the  patient,  and  sponge  holders.  In  addition  to  the  above,  a  tubular 
needle  with  a  reel  for  passing  wire,  a  wire-twister,  and  a  rectangular 
knife,  if  it  be  found  needful  to  take  a  flap  from  the  septum,  will  be 
found  useful. 

The  patient's  stomach  being  just  empty,  so  that  he  shall  not  vomit 
during  the  operation,  nor  want  food  immediately  after,  is  placed  on  a 
narrow  table  of  suitable  height,  and  in  a  good  light.  As  soon  as  he  is 
under  the  anesthetic,  his  hands  are  tied  to  the  bandage  which  secures 
him  to  the  table,  or  wrapped  in  a  jack-towel,  one  being  always  left 
Avithin  reach  of  the  chloroformist.  The  head  and  shoulders  being 
suitably  propped  up  Avith  firm  pillows,  Mr.  Smith's  gag  is  then  in- 
troduced, the  tongue  tucked  under  the  central  plate  and  the  jaws 
widely  opened.  The  gag,  which  is  never  to  be  tied,  is  then  held  by 
an  assistant  who,  at  the  same  time,  supj^orts  the  head,  and  moves  it  to 
suit  the  operator.      Another  assistant  hands  instruments  and  gives 

*  Did.  of  Surg  ,  Art.  "  Cleft  Palate." 


320  OPERATIONS    ON   THE    HEAD    AND    NECK. 

Other  help,  while  sponges  are  wrung  out  and  supplied  on  holders  hy 
a  nurse. 

The  edges  of  the  cleft  are  first  pared  in  one  of  two  ways — viz.,  by 
holding  in  the  tenaculum-forceps  the  tip  of  one-half  of  the  uvula, 
and  thus  making  the  soft  palate  tense,  and  then  paring  from  behind 
forwards ;  the  opposite  half  is  then  seized,  and  that  side  pared  from 
before  backwards;  or,  if  it  is  preferred,  the  surgeon  may,  after  making 
tense  the  soft  palate,  transfix  the  centre  of  each  cleft  alternately  with  a 
double-edge  tenotome,  and  cut  first  up  and  then  down.  In  either  case 
the  whole  of  each  side  should  be  made  raw,  and  with  as  wide  a  sur- 
face as  possible ;  it  is  the  anterior  angle  and  the  tip  of  the  uvula  which 
are  liable  to  remain  unrefreshed.  As  far  as  possible  this  should  be 
the  only  occasion  on  which  the  flaps  are  touched  with  the  forceps. 

The  sutures  may  be  made  of  wire  (without  kinks),  carbolized  silk, 
salmon-gut,  and  horsehair.  Of  these  Mr.  Smith  prefers  wire  for  the 
hard  palate  and  for  any  part  of  the  soft  in  front  of  the  uvula,  prefer- 
ring horsehair  for  the  uvula  itself. 

If  the  flaps  are  thick  and  abundant,  if  they  fall  easily  together,  the 
material  is,  I  think,  of  less  importance.  Each  surgeon  will,  in  difficult 
cases,  find  advantage  from  being  used  to  certain  sutures.  If  the  sur- 
geon has  tubular  needles,  and  if  both  sides  of  the  cleft  can  be  spanned 
at  once,  he  will  find  it  very  easy  to  work  with  silver  wire.  Salmon- 
gut  and  horsehair  seem  to  me  to  be  the  least  irritating  next  to  wire, 
and  very  easy  to  work  with  after  being  softened  for  ten  minutes  in  a  hot 
solution  of  carbolic  acid.  But  if  the  cleft  is  a  wide  one,  and  if  Aveling's 
method  is  preferred,  it  is  difficult  to  obtain  the  last  two  forms  of  suture 
in  sufficient  length,  and  carbolized  silk  should  be  fallen  back  upon. 

The  following  methods  will  be  found  useful  according  to  the  width 
of  the  cleft,  and  the  needles  used :  (1)  If  a  tubular  needle  is  at  hand, 
silver  wire  can  be  passed  with  great  facility,  if  the  cleft  be  a  narrow 
one,  save  in  the  case  of  the  uvula,  for  which  horsehair  should  be  used. 
(2)  If  the  cleft  be  a  wide  one,  the  sutures  may  be  passed  in  one  of  the 
two  following  ways  :  (a)  Aveling's  :  A  double  loop  of  suture — this  is 
much  more  easily  done  with  silk — is  passed  on  one  side  and  the  loop 
drawn  out  of  the  mouth  and  held  b3'  an  assistant;  a  single  suture  is 
then  passed  through  the  opposite  side  at  a  point  opposite  to  this,  and 
the  end  also  drawn  out  of  the  mouth ;  this  single  suture  is  then  looped 
into  the  double  one,  and  by  pulling  this  latter  back  the  single  one  is 
drawn  across  the  cleft.  (6)  Here  they  are  passed  much  as  in  uniting 
an  ovariotomy  wound.  A  needle  is  threaded  at  each  end  of  a  suture, 
and  one  is  first  passed  from  right  to  left  and  the  other  from  left  to 
right.  If  this  method  is  used  an  assistant  holds  one  needle  while  the 
surgeon  is  using  the  other,  and  in  this,  as  in  Aveling's  method,  the 


CLEFT    PALATE.  321 

sutures  must  be  sufficiently  long.  I  prefer  this  way,  using  small 
needles  of  different  curves. 

After  the  first  suture  is  passed  through  the  halves  of  the  uvula,  it 
should  be  used  to  make  the  edges  tense,  thus  doing  away  with  any 
need  of  the  forceps.  Attention  should  be  paid  to  inserting  the  sutures 
at  a  sufficient  distance  from  the  edge  and  a  due  distance  from  each 
other  so  as  to  duly  distribute  amongst  themselves  any  tension  that 
may  be  present.  In  passing  any  suture,  the  needle  point  should  be 
quickly  stabbed  through  at  the  intended  spot.  When  sufficient 
sutures  have  been  passed,  two  or  three  should  be  tied  (the  wire  being 
twisted  with  the  fingers,  with  a  twister,  or  torsion-forceps),  the  gut  and 
horsehair  requiring  a  third  knot.  Then  if  there  is  too  much  tension 
on  the  rest  longitudinal  incisions  may  be  made  on  each  side  of,  and 
parallel  to,  the  cleft.  The  length  of  these  relieving  incisions  must 
vary ;  they  usually  begin  on  a  level  with  the  highest  stitch  in  the  soft 
palate  and  run  backwards  about  midway  between  the  teeth  and  the 
cleft,  care  being  taken  not  to  prolong  them  so  far  back  as  the  posterior 
edge  of  the  palate,  or  dangerously  near  the  posterior  pterygo-palatine 
canal  (p.  324). 

The  amount  of  relief  which  the  above  incisions  give,  even  if  freely 
prolonged,  is  often  disappointing,  and  they  should  always  be  dispensed 
with  if  possible.  If  there  is  much  tension  the  surgeon  will,  I  think, 
usually  do  best  by  not  attempting  too  much. 

Throughout  the  operation  hcemorrhage  must  be  arrested  by  sponge- 
pressure,  and  as  little  wiping  as  possible  should  be  done,  otherwise  the 
secretion  of  viscid  mucus  is  much  increased.  The  surgeon  will  from 
time  to  time  have  to  suspend  his  operation,  to  allow  of  additional  chlo- 
roform being  given,  or  for  vomiting,  when  the  head  must  be  quickly 
turned  on  one  side. 

The  after-treatment  and  the  causes  of  failure  are  given  a  little  later, 
at  pp.  323-4. 

Operation  on  the  Hard  Palate.— The  edges  of  this  being 

pared,  an  incision  is  made  down  to  the  bone  with  a  small  stout  scalpel 
about  midway  between  the  cleft  and  the  teeth,  or  rather  nearer  the 
latter,  and  reaching  from  the  anterior  edge  of  the  cleft  to  the  posterior 
edge  of  the  hard  palate.  Through  this  incision  raspatories  of  suitable 
length  and  curve  are  introduced  next  to  the  bone  and  pushed  inwards 
till  their  points  appear  in  the  cleft.  By  to-and-fro  movements  the 
mucous  membrane  and  periosteum  are  separated  from  the  bone,  every 
possible  care  being  taken  to  raise  these  of  even  thickness  and  without 
laceration  or  button-holing.  The  chief  difficulty  will  be  met  with  at 
the  two  ends  of  the  bony  clefts.  If  the  anterior  extremity  of  the  gap 
reaches  as  far  as  a  point  just  behind  the  incisors,  much  difficulty  will 
be  met  with  in  separating  the  muco-periosteum  here,  and  the  surgeon 

21 


322 


OPERATIONS   OX   THE    HEAD    AND    JS'ECK. 


will  do  well  to  be  provided  with  two  or  three  small  raspatories  of  dif- 
ferent curves  *  Again,  at  the  junction  of  the  hard  and  soft  palates,  the 
soft  parts  are  firmly  bound  down  to  the  former  by  fibrous  tissue.  To  free 
them  a  pair  of  angular  scissors  should  be  used,  one  blade  being  placed 
under  the  micro  periosteum,  between  it  and  the  bone,  and  the  other 
passed  through  the  cleft,  above  the  soft  palate,  the  fibrous  tissue  being 
thus  divided  close  to  the  bony  palate. 

While  the  soft  parts  are  thus  separated  the  haemorrhage  will  be  free, 
but  always  yields  to  pressure,  either  with  sponge  or  with  a  finger. 

When  all  bleeding  has  stopped,  the  sutures  are  inserted  as  before, 
wire  or  salmon-gut  being  used  here. 

Tension  may  in  part  be  removed  by  prolonging  the  lateral  incisions 
backwards. 

Mr.  T.  Smith  points  out  that  in  bringing  together  the  halves  of  the 
palate  care  must  be  taken  to  evert  the  edges  of  the  cleft  with  a  small 
double  hook  in  passing  and  twisting  up  the  sutures. 

Sir  W.  Fergusson's  Method  t  (Figs.  76,  77).— This  surgeon, 
finding  that  even  in  his  hands  attempts  to  completely  close  the  hard 


Fig.  76. 


Fig.  77. 


A,  Preliminary  punctures  with  brad-awl  to  give  line  for  chisel. 

B,  Incisions  through  bone  completed  by  chisel, 
c,  Holes  in  hard  and  soft  palate  for  sutures. 

D,  Junction  of  hard  and  soft  p>alate. 

E,  Lateral  openings  subsequently  filled  up  by  granulations.    (Bryant.) 

palate  often  failed  owing  to  the  contraction  of  granulations,  by  which 
the  lateral  fiaps  were  drawn  back  to  their  original  position,  introduced 
the   following   modification,  which  he  especially  recommended  for 


*  Mr.  T.  Smith  {loc.  supra  eit.)  recommends  the  use  of  a  small  rectangular  knife 
here. 

t  Brit.  Med.  Journ.,  April  4th,  1874.  Sir  W.  MacCorraac  in  the  same  journal 
fMay  20th)  points  out  that  Dieffenbach  and  Wutzer  had  first  used  a  very  similar 
operation. 


CLEFT    PALATE  323 

apertures  in  the  hard  palate,  but  which  he  had  used  with  great  success 
in  a  complete  cleft  of  both. 

Sir  W.  Fergusson,  having  pared  the  edges,  divides  the  palate,  both 
soft  tissues  and  bone,  first  with  a  scalpel  and  then  with  a  chisel.*  about 
4  inch  from  the  margin  of  the  gap  on  each  side.  AVith  the  chisel 
pushed  up  into  the  nose  through  each  incision,  by  sUght  movements 
from  side  to  side,  each  lateral  portion  is  prised  towards  each  other 
until  they  meet  in  the  middle  line,  when  sutures  are  inserted  between 
the  pared  edges  of  the  soft  parts.  In  some  cases  sutures  were  inserted 
not  merely  into  these  edges,  but  were  passed  through  the  lateral  aper- 
tures right  across  the  gap.t  Hiemorrhage  is  arrested  by  plugging  the 
lateral  incisions,  if  needful.  Nowadays  some  aseptic  gauze  is  best  used 
for  this  purpose. 

Nasal-Flap  Method. — M.  Lannelongue  j  has  closed  several  clefts, 
involving  only  the  hard  palate,  by  means  of  a  rectangular  flap  brought 
down  from  the  side  of  the  septum  of  the  nose.  The  flap  is  marked  out 
by  a  horizontal  and  two  vertical  incisions — the  former  parallel  to  the 
edge  of  the  cleft  and  at  a  suitable  distance  above  it,  the  latter  extending' 
downwards  fi'oni  each  end  of  the  horizontal  one  to  the  angles  of  the 
cleft.  The  flap,  composed  entirely  of  the  mucous  membrane  of  the 
septum,  is  dissected  from  above  downward  with  a  curved  blunt  ele- 
vator, and  left  adherent  at  its  inferior  border.  The  opposite  edge  of 
the  cleft  is  then  freshened  by  the  removal  of  a  superficial  strip  t  inch 
broad,  and  the  upper  border  of  the  flap  attached  to  it  by  sutures. 

After-treatment. — A  small  injection  of  morphia  (gr.  i)  may  be 
given,  but  no  food  should  be  allowed  for  three  hours,  only  a  little  ice 
being  given  to  suck.  For  the  first  forty-eight  hours  milk  only  should 
be  allowed,  with  a  little  port  wine  and  water.  After  this,  yolks  of  eggs, 
arrowroot,  broths,  and  soups,  light  puddings,  jellies,  maj'  be  allowed 
increasingly  during  the  first  two  or  three  weeks.  After  the  first  week 
the  patient  may  get  up,  under  supervision.  There  should  be  no  hurry 
to  remove  the  sutures,  which  may  remain  for  two  or  three  weeks. 

*  Preceded  in  some  cases  by  drilling  a  line  with  a  chisel,  as  in  Figs.  76,  77,  drawn 
bv  Mr.  Rose  for  Mr.  Bryant's  Surgery,  vol.  i.  Figs.  184.  185. 

t  Sir  W.  MacCormac  i/oc  supra  cit.)  shows  that  Dieff'enbach  made  use  of  similar 
siitiires,  sometimes  securing  further  approximation  by  again  twisting  them  up  later  on. 
.Sir  W.  Fergusson  stated  his  belief  that  the  objections  which  at  first  arise  to  his  method 
are  not  valid — (1)  There  is  no  caries  or  necrosis ;  i  2)  there  is  no  dangerous  hsemorrhage  ; 
( 3)  there  is  less  risk  of  sloughing  than  by  the  old  method ;  (4)  the  lateral  incisions 
heal  well.  He  admits  that  if,  as  sometimes  occurs,  the  vomer  is  found  attached  by  its 
lower  margin  to  the  palate,  it  would  be  difficult  to  introduce  stitches.  But  approxi- 
mation alone  of  the  edges  would  probably  convert  the  gap  into  a  mere  chink,  avoiding 
ordinary  observation. 

+  Bull,  de  la  Soc.  de  Chir..  1877,  p.  472.  For  the  above  account  of  the  operation  I 
am  indebted  to  Stimson's  Operative  Surgery,  p.  315. 


324  OPERATIONS    ON    THE    HEAD    AND    NECK. 

Causes  of  Failure. — 1.  Vomiting;*  2.  Premature  cutting  of 
sutures  from  tension ;  o.  Hiemorrhage.  Serious  haemorrhage  in 
children,  either  at  the  time  or  hiter,  is  very  rarely  met  with,  but  it  is 
otherwise  in  adults. 

Mr.  H.  Marsh,t  in  the  case  of  a  patient  aged  twenty-one,  was  com- 
pelled to  plug  the  posterior  palatine  canal  owing  to  severe  haemorrhage 
on  the  sixth  day.  The  haemorrhage  recurred  twice,  the  last  being  as 
late  as  the  fourteenth  day,  and  was  arrested  on  each  occasion  by  the 
following  means:  "Searching  with  a  sharp-pointed  probe,  passed 
through  the  lateral  cut,  about  i  inch  in  front  of  the  hamular  process, 
which  can  be  easily  felt  through  the  soft  palate,  and  about  the  same 
distance  directly  inwards  from  the  wisdom  tooth,  I  felt,  after  two  or 
three  attempts,  that  I  had  fixed  the  probe  in  the  orifice  of  the  canal, 
and  at  the  same  time  the  patient  screamed  with  pain,  when  the  large 
posterior  palatine  nerve  was  touched.  A  wooden  plug,  made  by 
sharpening  a  piece  of  firewood,  was  then  passed  firmly  into  the  canal, 
by  holding  it  in  a  pair  of  strong  forceps  with  its  point  looking  upwards, 
and  a  little  backwards  in  relation  to  the  roof  of  the  mouth.  Directly 
the  plug  was  introduced  the  bleeding  ceased."  The  recurrence  was 
due  to  the  plug  slipping  out. 

4.  Whooping  cough.  5.  Exanthemata.  6.  Child  putting  his  finger 
into  the  wound.  7.  By  swallowing  of  solid  food.  8.  Feeble  condition 
of  the  child,  with  congenital  syphilis,  etc. 

REMOVAL  OF  GROWTHS  OF  THE  PALATE. 

Growths  here,  though  rare,  have  a  special  interest,  from  their  posi- 
tion, and  may  thus  be  briefly  noticed.  For  the  best  account  of  them 
I  would  refer  my  readers  to  a  very  helpful  paper  by  Mr.  Stephen 
Paget,!  ^^  which  the  following  points  are  brought  out:  (1)  The  chief 
groups  are  the  polypoid  and  warty,  the  adenomatous,  the  sarcoma- 
tous, and  the  carcinomatous;  this  last  including  the  encephaloid, 
which  are  very  rare,  and  the  epitheliomatous,  commencing  in  irrita- 
tion here  as  elsewhere.  (2)  That  it  is  hardly  possible  to  tell  before- 
hand to  which  group  the  growth  belongs.  (3)  Many  of  them,  especially 
the  adenomata,  can  be  shelled  out  with  surprising  ease.  (4)  That  the 
growth  itself  should  not  be  cut  into. 

*  Mr.  Mason  {Brit.  Med.  Journ.,  1872,  vol.  i.  p.  14)  gives  the  case  of  a  cliild,  aged 
nine,  in  whicli  the  vomiting  of  two  himbrici  led  to  failure. 

f  Clin.  Soc.  Trans.,  vol.  xi.  p.  71.  On  the  occasion  of  the  third  haemorrhage  tlie 
patient  was  in  a  state  of  profound  syncope.  The  suggestion  of  plugging  the  canal  was 
originally  made  by  Mr.  T.  Smith,  in  a  similar  case  also  successfully  treated  by  Mr. 
Willett. 

X  St.  Barth.  Hosp.  Eeps.,  vol.  xxii. 


REMOVAL  OF  THE  TONGUE,  325 

In  the  case  of  large  and  vascular  growths,  the  aids  of  splitting  the 
cheek  or  performing  a  preliminary  lar^-ngotomy  and  plugging  the 
fauces  (p.  347)  may  well  be  resorted  to. 

From  what  I  have  seen  of  two  cases  of  epithelioma  of  the  palate, 
starting  from  the  alveolar  process,  and  in  one  case  certainly  originating 
in  an  old  syphilitic  sore,  no  time  should  be  wasted  with  such  means 
as  the  application  of  acids,  or  the  cautery,  and  I  think  that  removal 
of  the  bone  itself  by  some  such  operation  as  that  of  Maisonneuve  (p. 
287)  is  preferable  to  attacking  the  growth  with  gouge  or  chisel. 


CHAPTER   X. 
REMOVAL  OF  THE  TONGUE  (Figs.  78,  79). 

Before  describing  the  different  operations  it  will  be  well  to  say 
something  with  reference  to  two  or  three  very  practical  points  which 
rise  up  with  every  case  of  tongue  cancer,  a  form  of  cancer  which,  it 
must  be  remembered,  is  very  frequent  and  increasing  in  frequency  ;* 
which  attacks  all  ranks  of  life  ;  which,  after  its  early  stage,  is  especially 
malignant  ;t  in  which,  finally,  an  operation  is  as  much  dreaded  and 
deferred  by  men  as  one  for  carcinoma  mamma  is  by  women. 

A  Pre-Oancerous  Stage. — However  tongue  cancer  begins,  it 
passes  through  the  above  stage,  i.e.,  a  stage  (the  duration  of  which  is 
unknown  and  varies  extremely)  in  which  inflammatory  changes  only 
are  present,  ulceration  and  other  changes  in  the  epithelium,  not 
amounting  as  yet  to  epithelioma,  but  on  Avhich  epithelioma  inevitably 
supervenes.  The  boundary  line  between  this  pre-cancerous  stage  and 
cancer  is  extremely  narrow ;  the  duration  of  this  stage  may  be,  and 
often  is,  extremely  brief. 

Aids  in  recognizing  this  stage :  (1)  The  duration  of  the  ulcer.  (2) 
Its  obstinacy  to  treatment.  (3)  The  age  of  the  patient.  (4)  Absence 
of  any  induration  or  fixity.  (5)  Careful  scraping  of  the  surface  of  the 
sore,  and  microscopic  examination.!    In  doubtful  cases,  after  cleaning 

*  Amongst  common  cancers — e.g.,  of  breast,  rectum,  uterus,  etc. — cancer  of  the 
tongue  stands  about  third,  although  so  rare  in  women.  Mr.  Barker,  in  his  carefully 
worked  out  article  on  "  Diseases  of  the  Tongue"  {Syst.  of  Surg.,  vol.  ii.  p.  578),  gives  a 
series  of  tables  showing  that  in  the  last  about  thirty  years  there  has  been  a  steady  in- 
crease from  2.6  to  11.5  per  cent. 

t  This  is  shown  in  the  following  facts:  (a)  The  rapidity  here  is  quite  different 
from  other  epitheliomata.  P^jiithelioma,  usually  thought  a  slow  cancer,  here,  in  a 
moist,  warm  cavity,  much  irritated,  and  never  dry  and  warty,  is  terribly  rapid.  (3) 
Gland  invasion  is  here  not  only  certain,  but  inevitably  early  as  well." 

X  Butlin  {Sarcoma  and  Carcinoma,  p.  154,  pi.  iv.  Figs.  1,  2,  3).  The  use  of  cocaine 
will  nowadays  facilitate  the  above  examination. 


326  OPERATIONS    ON    THE    HEAD    AND    NECK. 

the  surface,  scrape  lightly  with  a  spatula,  or  blunt  knife,  and  examine 
the  result  microscopically.  In  a  sore  not  yet  epitheliomatous  the  epi- 
thelium is  still  regular,  squamous,  flattened,  and  the  nuclei  small  and 
single.  In  an  ulcer  becoming  epitheliomatous,  the  cells  are  no  longer 
regular,  but  variable  in  shape  and  size,  oval  and  caudate,  instead  of 
square,  with  nuclei  large  and  multiple.  Not  infrequently  cell-nests, 
or  fragments  of  cell-nests,  may  be  found. 

Questions  Arising  before  Operation. 

The  oi)erating  surgeon  will  often  be  called  upon  to  give  an  answer 
to  the  two  following  questions :  Will  the  disease  be  permanently 
cured  ?  If  a  permanent  cure  is  impossible,  will  life  be  bettered  and 
prolonged  ? 

A.    Will  the  disease  be  permanently  cured? 

Really  permanent  cures  are,  as  yet,  too  few,  10  per  cent,  of  cases 
operated  on  (Barker)  ;*  13  per  cent.  (Butlin  ).t  The  explanation  of 
this  is  not  altogether  to  the  credit  of  our  profession.  Patients  and  we 
alike  are  too  often  both  to  blame.  The  gravity  of  the  disease  is  over- 
looked, the  time  of  the  "  pre-cancerous  stage  "  is  lost.  Because  tongue- 
cancer  is  so  often  preceded  by  syphilis,  or  local  irritation,  the  prac- 
titioner diagnoses  the  above,  and  suggests  them  as  the  essential  part 
of  the  mischief;  "  give  drugs  another  chance  " — e.g.^  potassium  iodide, 
potassium  chlorate,  mercury,  caustics.  To  these  there  are,  in  nearly 
every  case,  the  strongest  objections  in  the  pre-cancerous  stage.  Time 
is  lost,  strength  is  lost,  and  the  patient  is  lulled  and  befooled,  while 
all  the  time  the  vascularity  and  irritation  all  around  the  ulcer  are 
increased.  Furthermore,  the  patient  is  in  part  responsible  for  the 
delay,  as  he  very  naturally  dreads  the  operation,  exaggerating  its 
danger,  painfulness,  and  the  supposed  inevitable  loss  of  speech.  The 
above  delays  lead  to  "  cultivation  of  cancer  "  and  to  miserable  deaths. 
We  shall  never  be  able  to  successfully  combat  the  above  till  (1)  the 
importance  and  value  of  the  pre-cancerous  stage  are  recognized ;  (2) 
getting  cases  of  tongue-cancer  early, J  we  are  enabled  to  assure  the 
patient  that  removal  of  one-half  of  the  tongue  will  be  sufficient,  and 
that  half  can  be  safely  and  usefully  spared  to  him.  It  has  been  denied 
by  some  that  leaving  half  the  tongue  is  attended  by  any  good  result. 
From  an  experience  of  twenty-three  cases  of  removal  of  the  tongue,  I 
am  able  to  say  positively  that  a  patient  in  whom  the  tongue  has  been 

*  Log.  supra  cit.,  p.  604. 

t  Dis.  of  the  Tongue,  p.  295.  Mr.  Bntlin's  percentage  is  calculated  from  seventy 
cases.  He  is  inclined  to  doubt  whether  a  large  number  of  cases  would  afford  so  good 
a  percentage  of  recoveries. 

J  If  ulceration  has  been  persistent  for  longer  than  three  months,  permanent  recovery 
is  very  doubtful.  If  it  has  persisted  for  over  six  months,  if  more  than  one-third  of  the 
tongue  is  invaded,  if  the  floor  of  the  mouth  is  involved,  permanent  recovery  is  well- 
nigh  certainly  hopeless. 


REMOVAL  OF  THE  TONGUE.  327 

split  longitudinally  and  half  removed  has  in  that  which  is  left  a 
member  which  most  usefully  represents  the  tongue,  and  over  which 
the  patient  has,  in  spite  of  what  is  said  to  the  contrary,  most  service- 
able control.* 

B.  If  «  permanent  cure  is  impossible,  will  life  be  bettered  and 
prolonged  ? 

Cases  which  are  not  operated  on  die  within  eighteen  months,  many 
in  twelve  months.  An  operation  wisely  planned  and  well  carried  out 
often  gives  a  gain  of  six  or  eight  months.  This  is  a  gain  not  only  of 
time,  but  also  of  comfort.  Death  by  glandular  recurrence  in  the  neck 
is  less  painful  and  noisome  than  death  by  mouth-cancer.  No  one 
who  has  seen  much  of  tongue-cancer  will  have  any  difficulty  in 
answering  the  question  which  of  the  two  is  most  painful  to  the  patient 
and  distressing  to  those  around  him,  tongue-cancer  with  its  horrible 
fcetor,  profuse  and  foul  salivation,  its  agonizing  pain,  its  racking  ear- 
ache, or  recurrence  in  the  cervical  glands,  an  alternative  in  which  the 
patient  is  often  able  to  work  up  to  near  the  last,  and,  till  towards  the 
close,  is  free  from  the  agonizing  tenderness,  the  stinking  foetor,  the 
dribbling  of  foul  saliva,  and  the  slow  starvation,  day  by  day,  of  tongue- 
cancer.  Where  an  operation  is  certainly  attended  with  risk,  the  patient 
in  facing  it  may  be  relieved  by  the  assurance  that  a  life  prolonged  in 
hideous  misery  and  constant  agony  is  worse  than  death  following 
close  on  an  operation.  "  When  a  man  has  only,  suppose,  two  or  three 
years  to  live,  it  is  no  small  advantage  if  at  least  half  the  time  can  be 
spent  in  comfort  rather  than  in  misery,  and  in  profitable  work  rather 
than  in  painful  idleness  "  (Paget).  If  a  patient  cannot  make  up  his 
mind  to  an  operation,  and  is  losing  precious  time,  he  should  be 
warned,  without  being  unduly  frightened,  of  the  state  of  things,  alluded 
to  a  few  lines  above,  which  will  inevitably  follow.  Usually,  as  soon 
as  this  sets  in,  i.e.,  when  the  condition  of  the  tongue  renders  him  a 
nuisance  to  himself  and  others  with  the  disgusting  foetor,  the  constant 
dribbling  of  foul  saliva  which  cannot  be  swallowed,  the  weary  aching: 
day  and  night,  lit  up  into  agonizing  flashes  when  the  parts  are  touched 
or  moved,  the  patient  becomes  willing  to  run  any  risk.  But,  too  often,, 
by  this  time,  not  only  are  the  glands  already  enlarged,  but  the  mis- 
chief has  reached  the  floor  of  the  mouth  or  the  alveolar  mucous  mem- 
brane by  extension,  though  not  yet,  perhaps,  with  ulceration. 

Operations. — The  following  four  will  be  carefully  described,  viz..: 
(i.)  Whitehead's  (Fig.  78). 

(ii.)  Syme's  (Fig.  79). 

(iii.)  Kocher's  (Fig.  79). 

(iv.)  The  Ecraseur. 

*  In  a  patient  from  whom  I  removed  half  the  tongue,  two  and  a  half  years  ago,  the 
hypertrophy  of  the  remaining  half  is  very  marked,  and  the  speech  excellent. 


328  OPERATIONS    ON    THE    HEAD    AND    NECK, 

With  these,  certain  aids — e.g.,  slitting  the  cheek,  preliminary  laryn- 
gotom}^,  and  ligature  of  the  linguals — will  also  be  considered.  One  or 
two  other  methods  will  then  be  briefly  alluded  to. 

While  the  above  operations — and  I  allude  especially  to  the  first 
three — give  a  choice  which  will  enable  the  surgeon  to  meet  any  case 
of  tongue-cancer,  whichever  is  chosen  must  be  completely  carried  out 
"  niggling  "  operations  lead  inevitably  to  return  and  accelerated  growth 
in  the  tongue  itself. 

(i.)  Whitehead's. — The  advantages  of  this  are  very  great.  They 
are :  (a)  The  transverse  section  of  the  body  of  the  tongue  can  be  placed 
deliberately  well  behind  the  growth.  However  far  behind  the  growth 
the  loop  of  the  ecraseur  is  placed  before  the  operation,  and  however 
securely  it  seems  to  be  retained  in  situ  by  large  curved  needles,  as  the 
loop  is  tightened  up,  owing  to  the  enormous  strain  which  is  gradually 
applied,  the  needles  and  the  loop  are  forced  forwards  nearer  and 
nearer  to  the  growth.  Now  the  neighborhood  of  this  is  all  ready  to 
become  the  seat  of  malignancy.  All  around  the  growth  the  epithelial 
columns  are  ready  to  dip  down  into  the  vascular  connective  tissue 
beneath,  on  which  in  health  they  never  encroach.  Again,  the  parts 
around  are  loaded  Avith  inflammatory  cells,  soft  and  vascular.  If,  as 
is  very  likely,  owing  to  the  tremendous  tension  to  which  it  is  sub- 
mitted, especially  when  the  parts  are  very  soft,  the  loop  comes  crushing 
into  this  neighborhood  and  makes  the  section  here,  the  indipping  pro- 
cesses which  extend  for  some  distance  around  the  actual  epithelioma 
may,  owing  to  the  vascularity  and  inflammation  consequent  on  the 
operation,  break  out  into  speedy  recurrence.  Again,  the  insertion  of 
the  needles  which  are  intended  to  keep  the  loop  well  behind  the 
growth  is  not  always  an  easy  matter,  especially  if  the  growth  is  far 
back,  and  if  the  front  teeth  are  well  developed  whilst  the  molars  and 
pre-molars  are  too  deficient  to  allow  of  wide  opening  of  the  mouth 
with  a  gag.  (b)  The  resulting  wound  is  very  clean,  there  being  very 
little  laceration  and  no  charring.  The  slight  decomposition  which 
would  take  place  from  an  extensive  operation,  even  Avith  scissors,  is 
readily  checked  by  the  use  of  iodoform  and  ether.  The  advantage  of 
this  in  saving  a  patient,  whose  vitality  is  already  lowered,  from  the 
depressing  effects  of  being  liable  for  days  to  breathe  and  swallow  with 
a  fetid  sore  in  his  mouth,  in  securing  rapid  granulation  and  healing, 
and  thus  enabling  the  patient  to  be  early  propped  up,  and  soon  to 
ileave  his  bed,  must  be  obvious  to  every  surgeon  who  knows  how  great 
.the  risk  is  of  fatal  septic  bronchitis  in  these  cases.  For  the  same 
reason  secondary  hemorrhage  is  unknown,  (c)  The  instruments 
required  are  extremely  simple  and  few,  as  will  be  seen  from  the 
account  of  the  operation. 


REMOVAL  OF  THE  TONGUE.  329 

The  Operation. 

It  is  most  essential  that  the  anaesthetic  should  be  in  the  hands  of  a 
man  who  can  be  thoroughly  trusted.  It  is  often  taken  badly  in  these 
cases,  with  much  dyspnoea  and  restlessness  at  first ;  and  during  the 
operation,  owing  to  the  open  mouth  admitting  much  air,  and  the  fear 
of  interfering  with  the  operator,  the  patients  often  "  come  to  "  fre- 
quently. The  only  thing  is  to  get  them  well  under  at  first ;  later  on 
it  will  be  well  not  to  keep  them  too  much  under  the  influence  of  the 
anaesthetic,  in  order  that,  the  sensibility  of  the  larynx  not  being  lost, 
the  blood  may  not  enter  the  air-passages.  The  administrator  must 
watch  the  tint  of  the  lips,  the  veins  in  the  cheeks,  and  know  when  a 
little  blood  is  only  safely,  though  noisily,  bubbling  at  the  back  of  the 
fauces,  and  when  it  is  getting  into  the  trachea.  I  look  upon  the 
administrator  of  anaesthetics  in  these  cases  as  quite  as  important  as 
the  operator.  Two  reliable  assistants  are  needed  who  understand  the 
steps  of  the  operation,  one  to  take  the  gag  in  charge,  and  to  sponge 
when  needed,  and  the  other  to  hook  back  the  corner  of  the  mouth 
with  two  fingers  while  he  is  ready  to  sponge,  and  thus,  with  the  posi- 
tion of  the  head  over  to  this  side,  enable  the  blood  to  escape  freely 
from  the  wound  into  the  cheek  and  out  of  the  mouth  with  the  aid  of 
deft  sponging.  Two  nurses  slioukl  be  ready  to  supply  sponges  ;  these 
being  absolutely  clean,  soft,  thoroughly  wrung  out  of  iced  Condy's 
fluid,  and  firmly  secured  on  holders.  The  following  instruments 
should  be  close  to  the  operator's  right  hand,  viz.,  scissors,  a  pair  of 
torsion-forceps,  and  Spencer  Wells's  forceps,  a  needle  in  handle, 
threaded  with  stout  silk,  and  one  or  two  medium-sized  ligatures  of 
carbolized  silk.* 

A  good  light  is  absolutely  essential.  Daylight  close  to  a  window  is 
far  the  best.  If  it  is  needful  to  operate  when  the  above  cannot  be 
obtained,  as  in  a  succession  of  fogg}"  November  afternoons,  a  good 
lamp  light,  concentrated  by  a  laryngeal  mirror,  will  be  useful.  In 
making  arrangements  for  a  good  light,  the  surgeon  will  remember  that, 
while  the  removal  itself  takes  but  a  short  time,  getting  the  patient 
under  the  anaesthetic,  and  keeping  him  under  its  influence,  often  ren- 
der the  operation  much  prolonged.  It  may  not  be  suj^erfluous  to  add 
here  that  this  is  an  operation  which  calls  for  coolness  and  decision  on 
the  part  of  the  operator,  and  for  promptness  with  their  help  on  the 
part  of  all  those  who  assist.  No  crowding  on  the  operator,  no  obstruc- 
tion to  the  light  by  bystanders,  should  be  permitted  for  a  moment. 

Prelhninary  Laryngotoniy. — The  question  of  the  advisability  of 
this  operation  now  arises.    It  forms  no  part  of  a  "  Whitehead  "  proper. 

*  Mr.  Whitehead,  hearing  that  I  had  twice  operated  by  his  method  in  1881,  kindly- 
sent  me  a  pair  of  his  scissors.  They  are  rather  longer  than  usual,  perfectly  flat,  very 
sharp  up  to  the  tips,  which  are  square  and  blunted. 


330  OPERATIONS    ON    THE    HEAD    AND    NECK. 

The  operator  who  mtroduced  the  scissors  method,  and  whose  success 
with  it  is  so  well  known,  never,  I  believe,  uses  a  preliminary  laryn- 
gotomy.  In  my  first  six  cases  I  followed  him  closely.  In  the  later 
seventeen  I  have  performed  laryngotomy  on  several  occasions,  though 
I  fear  Mr.  Whitehead  will  consider  this  admission  on  my  part  as  a 
sign  of  "  falling  away."  With  a  wider  experience,  I  am  led  to  think 
very  highly  of  this  preliminary  step,  and  of  the  plugging  of  the  back 
of  the  mouth,  which  it  renders  safe,  and  I  do  so  for  this  reason.  With 
the  fauces  plugged,  and  the  patient  breathing  through  a  laryngotomy 
cannula,  the  surgeon  can  neglect  the  luemorrhage  more,  can  operate 
more  deliberately,  and  thus  (and  this  is  the  value  of  this  preliminary 
step  in  my  mind),  at  every  step  of  the  operation,  can  have  the  parts 
more  thoroughly  sponged  dry,  and  thus  be  enabled  throughout  to 
keep  more  surely  wide  of  the  disease.  In  other  words,  I  do  not  dread 
the  hemorrhage  which  accompanies  a  scissors-operation  for  itself,  but 
because  it  is  hable,  in  spite  of  careful  and  prompt  sponging,  to  obscure 
the  field,  and  thus  lead  to  cutting  dangerously  near  the  growth— a 
danger  especially  likely  to  happen  if  the  haemorrhage  is  at  all  free,  if 
the  parts  cut  are  very  much  softened,  and  if  the  patient  is  not  taking 
the  anesthetic  well.  For  these  reasons,  I  am  inclined  to  recommend 
a  preliminary  laryngotomy,  with  plugging  of  the  fauces,  in  these  cases : 
(1)  When  a  surgeon  who  values  Whitehead's  operation  is  doubtful  as 
to  his  means  of  meeting  hasmorrhage.  (2)  When  the  growth  extends 
beyond  the  middle  of  the  tongue,  into  the  posterior  third.  (3)  When 
the  floor  of  the  mouth  is  at  all  involved.  In  growths  limited  to  the 
anterior  half  of  the  tongue,  unless  there  is  much  fixity,  laryngotomy 
is  not  needed,  for,  as  will  be  seen  below,  sufficient  of  the  tongue  in 
such  cases,  after  very  little  use  of  the  scissors,  comes  right  out  of  the 
mouth. 

If  it  is  decided  to  perform  laryngotomy,  this  operation  is  done  as  at 
p.  847,  and  a  soft  clean  sponge,  dusted  with  iodoform,  is  tied  with  silk 
into  appropriate  size  and  fixed  at  the  back  of  the  fauces,  the  silk  being 
brought  out  of  the  mouth  and  held  by  a  finger  of  the  assistant  who 
has  charge  of  the  gag.  This  sponge  must  be  pressed  well  back,  and 
care  taken  that  it  does  not  draw  back  and  down  the  base  of  the 
tongue,  or  it  may  cause  some  difficulty  in  securing  the  Unguals  when 
the  transverse  section  of  the  tongue  is  made  far  back.  The  ansesthetic 
is  now  given  through  the  tube,  an  additional  advantage,  brought 
about  by  the  laryngotomy,  as  the  administration  of  the  anaesthetic 
does  not  interfere  with  the  field  of  operation.  So  very  little  sloughing 
and  swelling  of  parts  follows  on  Mr.  Whitehead's  operation  that  the 
laryngotomy  tube  may  be  removed  as  soon  as  the  patient  is  back  in 
bed  and  has  "  come  to  "  comfortably.  . 

Whether   laryngotomy   is    performed   or   not,   the   patient,   being 


REMOVAL   OF    THE   TONGUE. 


331 


propped  up,  is  brought  quite  to  that  side  of  the  table  on  which  the 
surgeon  stands.  A  gag*  is  placed  on  the  side  of  the  mouth  opposite 
to  the  growth,  and  the  mouth  widely  opened.  The  tongue  is  then 
transfixed  on  the  diseased  side  well  back  in  its  anterior  third,  with  a 
needle  in  a  handle  loaded  with  stout  silk,  this  is  looped  and  knotted, 
and  the  tongue  thus  well  drawn  out  of  the  mouth.  The  surgeon  then, 
with  a  sharp-pointed  bistoury,  splits  the  tongue  longitudinally  along 
the  raphe,  to  a  point  thoroughly  well  behind  the  growth.  This  is 
another  departure  from  a  strictly  performed  "  Whitehead,"  but  it  has 
the  following  advantages,  while  it  causes  no  troublesome  haemorrhage 
if  the  blade  be  kept  in  the  middle  line  :  (1)  If  the  whole  tongue  is  to 

Fig. 78. 


The  lower  of  these  figures  shows  "grooAing"  of  the  tongue,  preparatory  to  securing  the  lingual, 

p.  332. 

be  removed  it  places  the  hfemorrhage  much  more  under  the  control 
of  the  surgeon,  as  he  can  deal  with  each  half  separately,  and  with  one 
lingual,  securely,  at  a  time;  (2)  It  enables  the  surgeon  to  leave  half 

*  Of  these  I  prefer  Krohne  and  Seseman's  modification  of  Mason's  gag  as  tlie  best 
all-round  instrument.  It  was  first  brought  to  my  notice  by  Dr.  Hewitt,  who  has  found 
it  the  readiest  and  most  efficient  in  case  of  need  in  the  administration  of  anpesthetics. 
Mr.  Gowan's  gag  is  also  a  good  one,  but  I  have  found  it  liable  to  slip  in  sj)ite  of  its 
ingenuity.     A  gag  is  still  needed  for  edentulous  jaws. 


332  OPERATIONS    ON    THE    HEAD    AND    NECK. 

the  tongue  if  he  find  it  safe  to  do  so.  It  has  been  said  that  leaving 
half  the  tongue  is  useless,  the  part  left  being  but  little  under  the 
patient's  control.  I  am  of  an  opinion  entirely  different.  In  cases 
where  I  have  been  able  after  splitting  the  tongue  to  leave  half  of  it 
the  part  was  most  useful  both  in  speaking  and  swallowing,  etc.,*  and 
I  am  further  most  strongly  of  opinion  that  if  patients  could  be  assured 
that  half  only  of  the  tongue  would  be  removed  they  would  submit 
much  more  readily  to  an  operation  they  dread  so  peculiarly,  and  to 
the  grievous  putting  off  of  which  is  due  the  very  small  percentage  of 
permanent  cures.  . 

The  tongue  having  been  split  and  the  diseased  half  drawn  well  out 
of  the  mouth,  tlie  surgeon  next  divides  with  scissors  the  mucous 
membrane  between  the  tongue  and  the  alveolar  process,  keeping  close 
to  the  bone  so  as  to  be  wide  of  the  disease.  The  anterior  pillar  of  the 
fauces  is  next  divided.  While  the  above  steps  are  taken  the  two 
assistants  sedulously  sponge  away  any  hajmorrhage  into  the  hollow 
of  the  cheek  and  out  of  the  mouth,  the  cheek  being  retracted  as  above 
directed.  Careful  sponging,  and  sponge-pressure  on  bleeding  points, 
are  most  essential  if  the  surgeon  is  to  cut  wide  of  the  disease. 

If  the  disease  has  implicated  the  fr£enum  and  its  vicinity  two  or 
three  of  the  lower  incisors  should  be  drawn  so  that  the  scissors  may 
be  introduced  on  a  level  with  the  disease.  If  this  is  not  done  the 
scissors  have  to  be  dipped  in  over  the  teeth  in  an  awkward  way,  and 
one  which,  as  soon  as  bleeding  occurs,  makes  it  impossible  to  make 
sure  of  getting  below  the  disease.  The  scissors  can  be  introduced 
with  much  greater  facility,  and  used  to  much  better  purpose,  if  a  gap 
is  made  in  the  teeth.  These  can  be  kept  and  fitted  to  a  plate  later  on 
by  a  dentist. 

When  half  of  the  tongue  has  been  freed  all  round,  the  muscles 
between  it  and  the  floor  of  the  mouth  are  cut  through  with  a  series 
of  short  snii^s  until  the  diseased  half  is  separated  on  the  level  of  the 
lower. part  of  the  jaw,  as  far  back  as  is  needful.  During  this  stage 
oozing  will  take  place,  and  one  or  two  small  arteries  jet  with  varying 
freedom  in  different  cases,  but  these  will  yield  to  pulling  steadily  on 
the  tongue  and  to  firmly  applied  sponge-pressure. 

The  tongue  having  been  freed  horizontally  up  to  a  point  well  behind 
the  disease,  the  transverse  section  is  now  made,  and  here  I  have  found 
the  following  precaution  useful :  Instead  of  cutting  straight  across 
the  half  and  trusting  to  being  able  to  secure  the  lingual  on  the  face 
of  the  stump,  a  step  by  no  means  always  easy  of  accomplishment, 
owing  to  the  arter}'  being  often  at  once  obscured  by  a  small  pool  of 
blood,  and  to  the  not  unfrequent  softness  of  the  tissues  in  these  cases, 

■*  See  foot-note,  p.  327. 


REMOVAL  OF  THE  TONGUE.  333 

I  cut  a  deep  groove  through  the  tough  mucous  membrane  of  the  side 
and  dorsum  (Fig.  78),  and  tear  through  the  softer  muscular  tissue  with 
the  closed  scissors  or  a  steel  director  till  the  lingual  nerve  and  artery- 
are  seen,  then,  having  applied  a  long-bladed  pair  of  torsion-forceps 
to  the  remaining  tissues,  cut  awa}'  the  half  of  the  tongue  in  front  of 
the  forceps,  and  then  twist  or  tie  the  lingual  artery  which  has  thus 
been  secured.* 

If  it  be  needful,  the  surgeon  then  proceeds  to  deal  with  the  other 
half  of  the  tongue,  a  step  which  is  much  facilitated  by  the  room  given 
for  manipulation  by  the  removal  of  the  first  half 

Slitting  the  Cheek  (Fig.  79). — This  step  is  an  excellent  one.  It 
may  be  made  use  of  in  cases  where  the  disease  is  situated  very  far 
back,  extending  close  to  or  on  to  the  anterior  pillar  of  the  fauces, 
where  the  haemorrhage  is  expected  to  be  especially  free,  where  the 
light  is  unavoidably  very  bad,  or  where  there  is  unusual  difficulty  in 
getting  the  jaws  well  apart.  The  cheek  is  slit  as  far  back  as  the  ante- 
rior border  of  the  masseter,  the  facial  artery  and  other  small  branches 
being  secured  at  once.  The  parts  require  most  careful  adjusting  after- 
wards, especially  at  the  corner  of  the* mouth,  where,  from  the  dribbling 
of  saliva,  primary  and  exact  union  is  not  always  secured. 

rreliminorg  IJgatvre  of  the  TJugunfs. — This  step  has  been 
very  largely  practiced  by  Prof  Billroth.f  Unfortunately  he  expresses 
no  opinion  as  to  its  value.  He  states  that  he  ligatured  the  artery 
twenty-seven  times  (apparently  in  all  as  a  preliminar}^  step),  but  only 
adds  that  no  secondary  haemorrhage  ever  followed,  and  that  the  wound 
always  healed  satisfactorily. 

Dr.  Shepherd,  of  Montreal,  has  recorded  X  three  cases  in  which  he 
tied  both  Unguals  previous  to  excision  of  the  tongue,  which  operation 
was  bloodless. 

I  have  never  taken  this  precaution  myself,  and  I  do  not  recommend 
it,  for  the  following  reasons  :  (1)  In  three  cases  in  which  I  know  of 
this  precaution  having  been  taken,  the  haemorrhage  was  as  free  as  in 
the   usual  operation  with  scissors,  performed  without  any  such  pre- 

*  If  any  difBculty  occur  in  dealing  with  a  divided  lingual,  especially  if  the  tongue 
has  been  divided  far  back,  a  suggestion  of  Mr.  Heath's  will  be  found  most  useful — 
viz.,  to  hook  one  or  two  fingers  into  the  pharynx  over  the  stump  of  the  tongue,  and  to 
draw  this  forwards,  thus  at  once  arresting  the  haemorrhage  by  pressure,  and  bringing 
into  view  the  bleeding  point. 

t  Clin.  Surg.,  Syd.  Soc.  (translation  by  Mr   Dent),  p.  113.    . 

X  Ann.  of  Surg.,  November,  1885.  Mr.  Treves  [Lancet,  April  21,  18S3)  publishes 
four  cases  of  the  removal  of  the  tongue,  in  which  ligature  of  the  Unguals  was  resorted 
to.  The  haemorrhage  which  followed  on  the  operation  on  the  tongue  is  stated  to  have 
been  "  very  insignificant,  and  usually  immediately  arrested  by  firm  pressure  with  a 
sponge.  It  is  only  far  back,  in  the  region  of  the  tonsil,  that  any  bleeding  may  occur 
that  does  not  cease  almost  spontaneously." 


334  OPERATIONS    ON    THE    HEAD    AND    NECK. 

liminary*  (2)  I  think  that  an  experience  derived  from  operations  in 
twenty-two  cases  justifies  me  in  saying  that  if  the  operation  with  scis- 
sors be  performed  with  attention  to  the  details  given  above,  the  haem- 
orrhage is  not  so  difficult  to  deal  with  as  to  require  this  precaution.! 
(3)  The  ligature  of  both  Unguals  is  by  no  means  an  operation  that 
can  be  done  quickly ,;j:  and  requires  a  good  light.  It  may  thus  take 
up  a  good  deal  of  the  time  required  for  dealing  with  the  disease  of  the 
tongue  itself.  If  it  be  answered  that  diseased  glands  can  be  dealt 
with  at  the  same  time  and  by  the  same  incisions,  I  must  state,  in  no 
contradictory  spirit,  that  I  am  of  a  distinctly  contrary  opinion.  Re- 
moval of  epitheliomatous  glands  requires  of  itself  much  time  and 
painstaking,  lying,  as  they  do,  in  long  chains,  and  in  relation  with 
most  important  structures.  If  they  are  to  be  removed  with  that 
thoroughness  which  alone  justifies  any  attack  on  them,  this  should  be 
done  with  the  full  allowance  of  time  and  the  undivided  attention 
which  are  given  by  a  separate  operation,  either  before  or  after  that  on 
the  tongue. 

(ii.)  Syme's  Operation!  (Fig.  79). — This  consists  in  dividing  the 
symphysis  menti  and  then  removing  the  whole  tongue  and  floor  of 
the  mouth  with  knife  or  scissors,  or  partly  with  one  of  these  and  partly 
with  the  ecraseur. 

It  is  a  far  more  serious  operation  than  the  one  already  given,  and 
often  involves  prolonged  after-treatment,  owing  to  the  tardy  union  of 
the  jaw.  It  should  be  reserved  for  those  cases  in  which  the  ulcer  in- 
volves the  floor  of  the  mouth,  or  in  which,  in  addition  to  an  ulcer  on 
the  side,  a  hard  mass  of  infiltration  can  be  felt  in  the  substance  of  the 
organ.  Where  this  ojieration  is  contemplated  in  an  aged  or  broken- 
down  patient,  every  attempt  should  be  made  to  improve  the  general 
health  previously.  An  anaesthetic  being  given,  and  a  preliminary 
laryngotomy  performed,  the  patient's  head  and  shoulders  are  raised, 
and  the  surgeon  divides  the  soft  parts  of  the  chin,  as  far  down  as  the 
hyoid  bone,  if  the  soft  parts  in  the  floor  of  the  mouth  are  much  impli- 
cated. The  vessels  being  secured,  the  jaw  is  drilled  below  the  teeth  a 
quarter  of  an  inch  on  either  side  of  the  middle  line,  and  then  sawn 
through. II     A  sponge  is  now  placed  at  the  back  of  the  fauces,  and  the 

*  The  operations  were  here  performed  by  two  of  my  colleagues,  and  there  could  be 
no  doubt  that  the  vessels  were  secured. 

t  In  writing  this  I  am  taking  it  for  granted  that  the  surgeon  will  be  aided  by  helpers 
as  apt  and  ready  as  I  have  been  fortunate  enough  to  find. 

X  The  operation  will  be  fully  described,  and  its  difficulties  entered  into,  later  on. 

^  Lancet,  1858,  vol.  i.  p.  46,  and  vol.  ii.  p.  168.  See  also  the  account  by  Dr.  Fiddes 
of  his  case,  Edin.  Med.  Journ.,  vol.  iv.  p.  1092.  As  a  proof  of  the  severity  of  this  oper- 
ation both  of  Prof.  Syme's  first  two  patients  died. 

II  By  some  it  is  advised  to  saw  this  somewhat  angularly  instead  of  vertically  to  pro- 
mote interlocking  and  union  of  the  fragments.     As,  however,  necrosis  may  follow  this 


EEMOVAL  OF  THE  TONGUE.  335 

halves  of  the  jaw  being  forcibly  retracted,  the  tongue  is  well  drawn 
out  by  a  loop  of  silk,  the  mucous  membrane  snipped  through  between 
the  tongue  and  the  alveolar  process,  and  the  anterior  pillars  next 
divided.  The  genio-hyoglossi  *  and  genio-hyoids  are  next  divided, 
and  the  tissues  in  the  floor  of  the  mouth  separated  as  deeply  as  neces- 
sary with  the  scissors  or  blunt-pointed  bistoury  aided  by  the  finger, 
partly  by  cutting  and  partly  by  tearing,  any  vessels  that  require  it 
being  tied  or  twisted.  The  tongue  being  thus  freed  laterally  and 
below  as  far  back  as  is  needful,  the  transverse  section  is  made,  one-half 
at  a  time,  Avith  the  precautions  recommended  at  p.  332. 

The  floor  is  now  carefully  inspected,  and  any  suspicious  patches  or 
enlarged  glands  most  carefully  removed.  In  raising  the  former,  before 
using  the  scissors,  a  tenaculum  is  often  very  useful.  If  it  be  preferred, 
though  I  in  no  way  recommend  it,  as  soon  as  the  attachments  of  the 
tongue  to  the  floor  and  sides  of  the  mouth  are  sufficiently  divided,  the 
transverse  section  can  be  made  with  an  ecraseur,  the  loop  of  which  is 
slipped  over  the  tongue  and  kept  in  position  by  two  curved  needles  as 
at  p.  337. 

The  two  halves  of  the  jaw  can  then  be  wired,  but  to  promote  speedy 
union  a  cap  of  vulcanite  or  silver  had  best  be  fitted  on  to  prevent  dis- 
placement of  the  fragments.  A  drainage-tube  should  be  brought 
through  from  the  mouth  to  a  point  just  above  the  hyoid  bone,  before 
the  soft  parts  are  united  with  sutures. 

(iii.)  Kocher'st  Method,  by  Lateral  Infra-Maxillary  Inci- 
sion (Fig.  79). — This  operation,  like  the  last,  is  a  severe  one;  it  also 
opens  Uf)  freely  the  connective  tissue  of  the  neck.  It  has  the  great 
advantage  of  enabling  the  surgeon  to  deal  with  mischief  far  back  in 
the  tongue  and  at  the  sam.e  time  of  removing  enlarged  sub-maxillary 
glands.  Furthermore,  it  can  be  performed  antiseptically.  The  mouth 
being  disinfected  with  a  1  in  1000  perchloride  of  mercury  solution, 
and  a  preliminary  laryngotomy  performed,  an  incision  is  made  from 
just  below  the  symphysis  down  to  the  hyoid  bone,  and  following  the 
digastric  muscle  back  to  the  anterior  edge  of  the  sterno-mastoid,  and 
then  up  to  near  the  lobule  of  the  ear.  The  flap  thus  marked  out  of 
platysma  and  fascia?  is  then  turned  up,  and  the  fjicial  artery  tied. 
The  sub-maxillary  region  is  then  thoroughly  cleaned  out  and  the  Un- 
as well  as  the  other  form  of  bone-section,  the  longer  time  that  it  entails  is  scarcely 
worth  giving. 

*  If  only  one-half  of  the  tongne  need  removal — a  rare  contingency  in  the  cases 
which  call  for  this  operation — the  complete  separation  of  these  muscles  and  the  conse- 
quent danger  of  the  falling  back  of  the  tongue  will  alike  be  avoided. 

t  Bent.  Zeitsch.f.  Chir.,  Bd.xiii.  1880.  Mr.  Barker  was  the  first,  I  believe,  to  draw 
the  attention  of  English  surgeons  to  this  operation  ("  Diseases  of  the  Tongue,"  Syst.  o 
Surg.,  vol.  ii.). 


336 


OPERATIONS    ON    THE    HEAD    AND    NECK. 


gual  artery  secured  on  the  hyoglossus.  By  cutting  through  the  molo- 
hyoid  muscle  the  cavity  of  the  mouth  is  now  freely  opened  into,  and 
the  tongue  brought  out  through  the  wound  and  divided  as  far  back  as 


Fig. 


The  incisions  on  tlie  nose  are  those  of  Oilier  for  the  removal  of  naso-pharyngeal  polypi,  p.  286. 
Below  are  seen  three  for  the  removal  of  the  tongue — viz.,  that  for  slitting  the  cheek,  and  that  of 
Syme's  operation.  The  third,  that  of  Kocher,  should  have  been  brought  further  forward,  curv- 
ing up  towards  the  chin. 

is  needful,  one-half  being  removed  after  splitting  the  organ,  or  the 
whole  tongue  removed,  the  opposite  lingual  being  tied  if  needed. 

The  large  wound  is  then  carefully  packed  with  strips  of  antiseptic 
gauze,  a  drainage-tube  being  first  inserted.  The  patient  continues  to 
breathe  through  the  laryngotomy  tube  until  the  wound  and  mouth 
are  quite  sweet,  and  thus  there  is  no  danger  of  septic  broncho-pneu- 
monia. 

If  it  be  desired  to  conduct  the  operation  as  strictly  antiseptically 
as  possible,  before  it  is  begun,  plugs  of  salicylic  wool  must  be  placed  in 
the  nose,  the  cavity  of  the  mouth  well  washed  out  with  1-2000  mercury 
perchloride  solution,  and  the  spray  used  at  the  operation  and  at  each 
dressing.  As,  however,  it  is  impossible  to  render  aseptic  the  closely 
contiguous  cavities  of  the  posterior  nares  and  pharynx,  and  as  the 
patient  will  require  feeding  at  regular  intervals  with  a  nasal  tube,  I 
would  prefer  to  trust  to  sufficiently  frequent  changes  of  the  gauze  with 
wdiich  the  wound  is  plugged,  dusting  on  iodoform  and  powdered 
boracic  acid,  painting  on  with  a  camel's-hair  brush  iodoform  and  ether, 
and  securing  free  drainage  by  a  drainage-tube  which  has  one  end 


REMOVAL  OF  THE  TONGUE.  337 

brought  out  of  the  mouth  and  the  other  at  the  lower  and  posterior 
angle  of  the  wound,  both  lodged  m  aseptic  dressings. 

(iv.)  The  Ecraseur. — This  may  be  used  in  different  ways ;  the 
two  following  are  the  chief  ones  : 

1.  Through  the  "mouth,  in  combination  with  scissors,  a  method 
used  by  Mr.  Baker.^ 

2.  By  means  of  a  puncture  in  the  sub-maxillary  region,  or  through 
a  wound  which  has  to  be  made  here  in  the  removal  of  enlarged 
glands. 

The  first  of  these  only  will  be  described  here,  as,  if  the  ecraseur  has 
to  be  made  use  of,  it  is  by  far  the  simplest  and  speediest  method  of 
using  it. 

In  addition  to  the  instruments  already  given  in  the  description  of 
the  operation  with  scissors,  the  surgeon  must  be  provided  with  a  stout, 
short  ecraseur,  curved  on  the  fiat,  working  smoothly  and  carrying  a 
strong  loop  of  whipcord. f 

The  first  part  of  the  operation  resembles  that  given  at  p.  330.  The 
tongue  being  well  drawn  out  with  a  silk  loop,  the  anterior  pillar  and 
the  mucous  membrane  between  the  alveolar  margin  and  the  tongue 
being  cut  through,  the  tongue  is  then  split  with  a  bistoury  along  the 
raphe  as  far  back  as  is  needful,  and  its  attachments  to  the  floor  of  the 
mouth  partly  snipped  through  with  scissors,  partly  torn  through  with 
the  finger.  The  tongue  being  now  freed  sufficiently  to  make  the 
transverse  divisions,  two  slightly  curved  needles,  in  handles,  are  made 
to  perforate  the  tonge  a  full  inch  behind  the  posterior  limit  of  the  dis- 
ease, and  the  loop  is  then  slipped  on  and  adjusted  behind  the  needles. 
Before  doing  this,  I  would  strongly  recommend  that  a  groove  be  cut 
with  the  scissors  throvigh  the  mucous  membrane  of  the  dorsum  and 
sides  of  the  tongue  (p.  332) ;  this  simple  step  will  serve  to  steady  the 
bite  of  the  ecraseur  and  lessen  the  risk  of  its  gradually  coming,  as  it 
is  tightened  up,  dangerously  near  the  growth,  and  it  will  also  shorten 
the  time  that  the  loop  takes  to  effect  its  work.  When  first  adjusted,, 
the  ecraseur  may  be  worked  more  quickly,  but  as  soon  as  real  resistance 
is  felt  the  screw  must  be  turned  more  slowly,  a  half  or  three-quarter 
turn  being  made  every  minute,  or  at  longer  intervals  if  the  loop  seems 
to  be  cutting  too  quickly.  It  should  always  be  remembered  that,  if 
oozing  takes  place  from  hurried  use  of  the  ecraseur,  it  will  be  far  more 
difficult  to  arrest  on  a  surface  bruised  by  this  instrument  than  on  one 
clean  cut  by  scissors.^ 

*  Lancet,  April  10,  1880;  Diet,  of  Sarg.,  vol.  ii. 

f  Not  of  wire.     See  the  next  foot-note. 

X  Mr.  Butlin  {Dis.  of  the  Tongue,  p.  334)  gives  the  following  case:  The  only  instance 
of  death  from  haemorrhage  "  in  my  table  occurred  in  the  case  of  a  man  whose  tongue 
was  removed  with  a  strong  wire  Ecraseur,  which  cut  through  the  tissue  of  the  tongue 

22 


338  OPERATIONS    ON    THE    HEAD    AND    NECK. 

If  the  whole  tongue  is  removed,  the  ecraseur  should  always  he  ap- 
plied to  each  half  separately.  Making  the  transverse  section  across 
the  whole  tongue  at  once  is  most  tedious,  and  the  gi'eat  strain  is  likely 
to  be  too  much  for  the  loop  or  instrument  itself.  It  also  causes  the 
constricted  tongue  to  swell  into  a  large  livid  mass,  which  much  ob- 
structs the  breathing ;  and  if,  as  is  likely,  both  the  Unguals,  which  are 
left  to  the  last,  are  divided  simultaneously,  the  furious  spirting  of  these 
vessels  in  two  crossing  streams  is  most  embarrassing. 

I  do  not  recommend  the  use  of  the  Ecraseur,  for  these  reasons : 

1.  However  well  behind  the  disease  the  loop  is  placed  at  first  (a  step 
by  no  means  easy  to  secure  where  the  disease  is  situated  far  back),  as 
it  is  slowl}^  tightened  up  it  tends  to  come  forward  (even  when  a  groove 
has  been  cut  in  the  mucous  membrane),  gradually  grinding  the  nee- 
dles placed  to  keep  it  in  position  and  the  loop  closer  and  closer  upon 
the  diseased  area,  or,  if  not  actually  into  this,  into  one  from  its  close 
contiguity  ready  to  take  on  disease  (p.  328). 

2.  I  have  seen,  again  and  again,  however  carefully  the  tightening 
of  the  loop  has  been  managed,  that  this  is,  finally,  not  fine  enough  to 
divide  the  lingual  artery  which  is  dragged  out  in  the  eye  of  the  loop, 
and  has,  after  all,  to  be  secured  by  ligature  or  torsion,  often  not  with- 
out previous  furious  bleeding. 

The  galvanic  ecraseur  has  not  been  described.  I  mention  it  here 
only  to  condemn  it.  During  the  operation  the  loop  may  break,  or  it 
may  cut  its  way  too  rapidly  through  the  softened  tissues,  especially  if 
the  heat  used  is  too  great.  Later  on,  the  patient  has  still  to  run  the 
gauntlet  of  the  risks  of  septic  lung  trouble  and  secondary  hfemorrhage 
which  the  use  of  this  treacherous  instrument  entails. 

After-treatment. — The  chief  objects  here  are:  (1)  To  keep  the 
wound  sweet;  (2)  to  give  sufficient  food. 

Several  English  surgeons  have  lately  drawn  attention  to  Kocher's 
method,  already  alluded  to,  of  packing  the  wound  with  antiseptic 
gauze  and  bringing  a  drainage-tube  out  into  the  submaxillary  region. 
Mr.  Butlin  gives,  with  especial  care,  the  details  with  which  this  method 
has  been  employed  by  Kocher  himself,  who  lost  only  one  patient  from 
the  operation  in  fourteen  cases,  and  by  Billroth,  whose  results,  pub- 
lished by  Wollfiler,  show  the  last  seventeen  cases  thus  treated  to  have 
been  all  successful. 

I  have  not  myself  made  use  of  this  method,  for  these  reasons :  I 
consider  (1)  that  other  means  give  as  good  results,  and  in  a  way  more 


like  a  knife,  much  more  quickly  and  cleanly  than  had  been  intended.  There  was 
some  smart  haemorrhage  at  the  time,  and  it  was  not  easy  to  get  the  man  out  of  the 
operating  theatre  alive.  The  artery  was  not  thoroughly  secured,  the  bleeding  re- 
curred, and  the  patient  sank  and  died  a  few  hours  later." 


REMOVAL  OF  THE  TONGUE.  339 

agreeable  to  the  patient,  and  I  may  add  here  that,  out  of  twenty- three 
cases  of  Whitehead's  method,  I  have  only  lost  one  from  the  operation.* 
(2)  That  this  method  of  packing  with  gauze  does  not,  and  cannot,  give 
absolutely  reliable  aseptic  results.  It  would,  I  think,  be  easy  to  prove 
this  from  the  constant  soaking  of  saliva  and  other  matters,  in  which 
this  wound  differs  from  others,  but  no  better  proof  can  be  given  than 
the  fact  that  a  patient  on  whom  Mr.  Butlin  himself  made  trial  of  this 
method  died,  on  the  eighth  day,  of  septic  pneumonia. 

The  treatment  I  have  made  use  of  is  as  follows :  For  some  days 
before  the  operation,  I  make  the  patient  practice  f  frequently  washing 
out  his  mouth  with  Condy's  fluid,  sitting  up,  and  with  the  head  alter- 
nately dependent  to  either  side.  He  also  gets  used  to  feeding  himself 
with  a  drainage-tube  attached  to  a  feeder-spout  and  passed  by  himself 
to  the  back  of  his  throat.| 

After  the  operation,  the  cut  surface  is  brushed  over  with  a  solution 
of  zinc-chloride,  gr.  x.-^j,§  or  iodoform  in  ether;  of  the  two,  I  prefer 
the  latter  at  this  time.  Morphia  is  given  as  freely  as  is  safe,  with  ice 
to  suck,  and  if  the  patient's  condition  is  low,  milk  and  brandy  are  ad- 
ministered either  by  a  soft  oesophageal  tube  or  by  enemata.  But  I  have 
generally  found  that,  after  the  first  six  hours,  a  patient  previously  prac- 
ticed in  the  matter  will  give  himself  sufficient  food.  1 1 

After  the  patient  has  had  his  first  sleep,  the  surface  is  washed  over, 
every  two  or  three  hours  at  first,  with  iodoform  and  ether,  and  the 
patient  is  soon  encouraged  to  sit  up  and  wash  out  his  mouth  constantly 
with  Condy's  fluid.  He  should  be  kept  warm  and  free  from  draughts, 
and  either  propped  up  or  turned  on  to  either  side.  I  try  that  my  pa- 
tients sit  up  a  little  on  the  second  day,  if  possible,  and  get  them,  when 
this  is  feasible,  into  an  aruichair  by  the  fifth  or  sixth  day.  Yolks  of 
eggs,  arrowroot,  soujjs,  pulped  vegetables  in  broths,  and  such  like  are 
soon  added  to  the  milk  and  brandy. 

Causes  of  Failure. 

(1)  Broncho-pneumonia.  Pneumonia.  Abscess  and  gangrene  of 
the  lungs.  These  must  be  placed  first  on  account  of  their  frequency. 
Septic  in  their  nature,  and  due  to  the  patient  breathing  foul  gases,  and 

*  The  patient  here  was  a  Jew,  prematurely  aged,  with  epithelioma  supervening  on 
syphilis,  who  died  on  the  eighth  day  of  broncho-pneumonia.  I  fear  that  this  was 
septic,  though  my  colleague,  Dr.  Mahomed,  who  saw  the  patient  during  life,  and  who 
made  the  post-mortem  examination,  being  influenced  chiefly  by  the  sweet  condition  of 
the  mouth,  was  of  a  different  opinion. 

t  This  gives  him  something  to  occupy  his  mind,  and  cleanses  the  mouth. 

I  If  the  patient  is  at  all  intelligent  he  will  do  this  for  himself  far  more  painlessly 
than  an  assistant  can. 

§  No  stronger  solution  should  be  used  for  fear  of  causing  cellulitis  in  the  sub-max- 
illary regions. 

II  If  this  is  not  the  case,  a  soft  tube  must  be  passed. 


340  OPERATIONS    ON    THE    HEAD    AND    NECK. 

drawing  down  putrid  fluids  into  his  lungs,  the  treatment  must  be  pre- 
ventive, every  endeavor  being  made  to  keep  the  mouth  sweet,  and  to 
relieve  the  patient's  breathing  by  attention  to  the  details  already  given. 

(2)  Haemorrhage.  This  is  rarely  met  with  at  the  time  of  the  oper- 
ation or  soon  after,  if  every  spirting  artery  has  been  properly  secured. 
It  will  also  be  rarely  met  with  as  a  secondary  complication  if  the 
wound  has  been  kept  sweet.  In  cases  of  bleeding,  if  the  application 
of  a  silk  ligature  to  the  bleeding  point  taken  up  by  a  Spencer  Wells's 
forceps  or  a  tenaculum  is  impossible,  firm  pressure  with  a  sponge  on 
a  holder  should  be  made  use  of  after  all  clots  have  been  removed.  If 
the  wound  is  foul,  it  must  be  cleansed  by  brushing  it  over  with  iodo- 
form and  ether,  or  with  turpentine — a  most  powerfully  cleansing 
styptic,*  and  one  always  to  be  used  in  preference  to  perchloride  of  iron. 
If  all  the  above  fail,  either  api^lying  and  leaving  in  situ  a  pair  of 
Spencer  Wells's  forceps,  packed  around  with  soft  gauze,  or  ligature  of 
the  lingual,  must  be  resorted  to. 

(3)  Cellulitis.     Erysipelas. 

(4)  Pyaemia. 

(5)  Exhaustion — more  rarely,  shock. 

(6)  CEdema  of  the  glottis. 

(7)  Suffocation  from  falling  back  of  the  tongue. 

(8)  Recurrence. 


CHAPTER  XI. 
OPERATIONS  ON  THE  TONSIL. 

REMOVAL  OF  NEW  GROWTHS  OF  THE  TONSIL. 

The  new  growths  here  are  most  commonly  round-celled  sarcomata 
and  epitheliomata. 

In  sarcomata  there  is  steady  enlargement  of  one  tonsil  in  an  adult, 
without  pain  at  first  or  inflammation,  a  globular  swelling,  the  size  of 
a  walnut,  making  its  appearance,  firmly  elastic,  and  tending  to  infil- 
trate adjacent  structures.! 

In  the  epitheliomata,  the  patients  are  older:  the  mischief  often 
begins  "as  a  sore  throat."  The  mass  occupying  the  site  of  the  tonsil 
is  now  much  harder  and  soon  ulcerates,  forming  an  excavated  ulcer 
with  the  characters  of  epithelioma.     The  base  of  the  tongue  may  be 

*  If  the  bleeding  is  of  the  nature  of  oozing,  one  or  two  injections  pf  ergotin  should 
certainly  be  tried. 

f  Especially  the  lyiuplmtic  glands  [vide  infra). 


NEW    GROWTHS    OF   THE   TONSIL.  341 

involved  secondarily.  Dysphagia,  emaciation,  etc.,  are  more  rapid 
here. 

Before  describing  any  operations  for  removal  of  tonsillar  growths,  it 
is  right  to  allude  to  their  great  malignancy,  owing  to  the  rapidity  with 
which  the  glands  are  affected.  In  this,  rather  than  in  the  importance 
of  its  relations,  lies  the  failure  of  operations  on  the  tonsil,  and  no  one 
who  has  watched  the  rapidity  with  which  enlargement  of  the  glands 
at  the  angle  of  the  jaw  takes  place  in  subacute  tonsillitis,  will  wonder 
at  this. 

Mr.  Butlin*  writes  on  this  point:  "So  early  in  the  course  of  the 
disease  are  the  glands  affected  that  they  may  appear  as  large  swell- 
ings in  the  neck,  within  a  few  weeks  of  the  period  at  which  the  first 
signs  of  the  disease  were  noticed  by  the  patient.  On  the  other  hand, 
there  may  be  no  visible  or  tangible  glandular  enlargement  until  six  or 
more  months  have  elapsed  from  the  first  occurrence  of  enlargement  of 
the  tonsil.  The  disease  proves  fatal,  in  very  many  instances,  within 
a  year,  or  even  six  months  of  its  first  appearance ;  indeed,  few  per- 
sons survive  for  more  than  three-quarters  of  a  year." 

Operations. 

A.  Through  the  Mouth. 

B.  By  Incision  in  the  Neck. 

A.  Through  the  Mouth. — This  method  can  only  be  made  use  of 
(a)  in  the  very  early  stage  of  tonsillar  new  growths,  when  there  is  no 
evidence  of  glandular  enlargement;  or  (b)  when  epithelioma  of  the 
tonsil  coexists  with  a  similar  condition  of  the  tongue. 

In  such  cases,  the  patient's  head  being  suitably  raised  and  supported, 
in  a  good  light,  the  cheek  on  the  affected  side  is  divided  from  the 
angle  of  the  mouth  to  the  masseter,  and  the  two  ends  of  the  facial 
artery  tied  or  twisted.  The  mouth  is  now  kept  widely  open  by  a  gag 
inserted  on  the  opposite  side,  the  tongue  drawn  out  of  the  mouth,  and 
the  masseter  pulled  backwards  by  a  retractor.  As  much  room  and 
light  as  possible  being  thus  obtained,  the  surgeon  divides  the  soft  pal- 
ate first  in  the  middle  line,  and  then  from  within  outwards  with  a 
Paquelin's  cautery ;  he  next,  either  with  the  same  instrument  or  with 
a  blunt  dissector  and  his  nail,  dissects  around  and  enucleates  the  ton- 
sil with  the  anterior  pillar. 

Where  the  growth  is  at  all  cauliflower-like  in  its  prominence,  the 
chief  part  may  be  first  removed  with  a  heated  wire  or  with  the  Paque- 
lin's cautery,  so  as  to  get  more  room  in  dealing  with  the  base.  In  any 
case  the  cautery  must  be  used  at  a  dull  red  heat  only  for  fear  of 
haemorrhage.  The  surgeon  must  be  prepared  for  its  leaving  indurated 
tissues  which  may  simulate  deposits  of  growth,  and  for  the  tendency 


*   Oper.  Surg,  of  Malig.  Dis.,  p.  174. 


342  OPERATIONS    ON    THE    HEAD    AND    NECK. 

of  the  instrument,  as  it  is  quickly  cooled  down  by  its  contact  with 
succulent  tissues,  to  stick  to  them.  A  little  additional  heat  frees  it  at 
once,  far  more  satisfactorily  than  pulling  it  away. 

Mr.  Butlin  points  out  that  some  of  the  new  growths  met  with  here 
are  so  easily  separable,  so  circumscribed,  if  not  encapsuled,  that  there 
is  not  the  least  difficulty  in  shelling  them  out.* 

Before  or  during  the  above  operation  the  surgeon  must  be  guided 
by  the  character  of  the  growth  and  other  facts  as  to  the  advisability 
of  performing  a  preliminary  laryngotomy. 

B.  By  Incision  through  the  Neck. 

(1)   CJceevers's  Method. 

The  following  clear  account  of  the  above  method,  slightly  modified, 
is  taken  from  a  case  of  Mr.  Golding  Bird's.f  "  An  oblique  incision 
was  made  from  the  lobule  of  the  left  ear,  downwards  and  forwards,  to 
the  hyoid  bone.  The  superficial  structures  and  deep  fascia  were 
divided,  a  branch  of  the  external  jugular  vein  alone  requiring  liga- 
ture. 

"An  enlarged  lymphatic  gland  was  shelled  out  and  the  digastric 
exposed.  This  and  the  stylo-hyoid  were  then  divided,  and  a  second 
hard  gland  being  found,  it  was  also  removed ;  it  lay  against  the  inter- 
nal jugular  vein.  On  retracting  the  posterior  border  of  the  wound 
and  pulling  forwards  the  angle  of  the  jaw,  the  stylo-glossus  and  stylo- 
pharyngeus  were  seen  and  divided,  fibre  by  fibre,  on  a  director. 
Neither  the  hypoglossal  nerve  nor  the  glosso-pharyngeal  was  observed. 
The  fascia  investing  the  posterior  part  of  the  submaxillary  gland  was 
now  slit  up,  and  the  facial  artery  ligatured  and  divided.  The  inter- 
nal jugular  vein  was  now  fully  exposed  for  more  than  1  inch.  The 
internal  carotid  was  not  seen,  but,  covered  with  fascia,  was  felt  pul- 
sating. These  two  vessels  being  drawn  outwards  by  a  retractor,  the 
wall  of  the  pharynx  was,  by  tearing  through  some  yellow  fat,  fully 
exposed,  bulging  to  and  fro  with  the  respiration.  No  vessel  save  the 
two  already  named  required  securing ;  and  at  the  upper  part  of  the 
wound  was  what  appeared  to  be  the  pes  anserina.  A  second  incision 
was  now  made  through  the  cheek  from  the  angle  of  the  mouth  %  to- 


*  Loc.  svpra  cit  jY).  175.  Mr.  Butlin  allows  that,  unfortunately,  recurrence  is  not 
less  probable  after  shelling  out.     I  prefer  the  method  already  given. 

t  Clin.  Soc.  Trans.,  vol.  xvi.  p.  9.  The  case  was  one  of  epithelioma,  in  a  patient 
aged  forty-five. 

X  In  Cheevers's  method  the  second  incision  is  made  along  the  horizontal  ramus  of 
the  lower  jaw.  If  this  is  made  use  of,  it  is  made  at  the  beginning  of  the  operation, 
and  the  flap  thus  marked  out  thrown  down.  This  would  give  more  room  for  the  sub- 
sequent dissection  (especially  in  a  stout  patient),  and  would  be  more  likely  to  expose 
enlarged  glands.  The  incision  through  tlie  cheek  might  be  made  as  well,  later  on,  as 
in  Mr.  Golding  Bird's  case. 


NEW   GROWTHS   OF   THE   TONSIL.  343 

wards  that  of  the  jaw.  There  was  no  hsemorrhage,  as  the  facial  artery- 
had  ah'eady  been  secured.  With  the  Jeft  forefinger  in  the  mouth  and 
the  right  in  the  wound,  the  enlarged  tonsil  could  easily  be  moved  be- 
tween them,  and  it  was  removed,  together  with  the  adjacent  piece  of 
the  pharyngeal  wall,  by  the  electric  cautery,  employing  this  partly  as 
a  knife  and  partly  as  an  ecraseur."* 

The  patient  made  a  very  good  recovery,  air  ceasing  to  pass  through 
the  wound  in  the  neck  on  the  16th  day. 

In  spite,  however,  of  the  thoroughness  of  the  operation  the  disease 
recurred  in  the  glands  within  six  weeks,  and  within  two  months  it 
returned  in  the  throat  as  well. 

The  following  remarks  of  Mr.  Golding  Bird  deserve  most  careful 
consideration.  After  speaking  of  the  entire  feasibility  of  the  opera- 
tion, he  says  :  "  The  question  of  expediency,  however,  demands  the 
fullest  attention ;  and  I  am  inclined  to  think  that  the  plan  adopted  in 
my  second  case  referred  to — namely,  feeding  by  a  soft  oesophagus 
tube,  with  the  alternative  eventually  of  performing  gastrotomy,  more 
likely  to  meet  all  the  real  requirements  of  these  cases,  unless  seen  so 
early  that  there  can  be  no  suspicion  of  the  growth  having  extended 
be3'ond  the  tonsil,  nor  of  having  invaded  the  lymphatic  system  except 
to  a  very  limited  and  remediable  extent." 

The  account  of  the  next  two  operations  is  taken  from  Mr.  But- 
lin.f 

(2)  Czerny''s  Method. 

A  f)reliminary  tracheotomy  having  been  performed,  and  the  larynx 
or  fauces  plugged,  an  incision  is  made  downwards  and  outwards  from 
the  angle  of  the  mouth  to  the  anterior  border  of  the  masseter,  and 
beyond  it  to  the  level  of  the  hyoid  bone.  Through  this  incision  the 
lower  jaw  is  exposed  and  sawn  through,  between  the  second  and  third 
molars,  from  above  downwards  and  outwards,  and  the  two  fragments 
are  held  asunder.  The  growth  is  by  this  means  laid  bare,  and  to  re- 
move it  it  may  be  necessary  to  divide  the  digastric,  stylo-hyoid,  and 
stylo-glossus  muscles,  and  the  hypo-glossal,  glosso-pharyngeal  and 
gustatory  nerves,  as  well  as  the  lingual  and  other  vessels.  The  growth 
is  then  cut  or  torn  out,  and  the  bleeding  points  are  touched  with  the 
cautery.  The  wound  is  thoroughly  washed  out  with  carbolic  lotion, 
or  dusted  with  iodoform,  the  fragments  of  the  lower  jaw  wired,  a  sec- 
ond wire  twisted  round  the  adjacent  molars,  and  the  external  wound 
closed  with  sutures,  except  at  points  for  the  exit  of  drainage  tubes, 

*  Mr.  Golding  Bird,  in  his  remarks  on  this  case,  stated  that  in  another  case  he 
should  open  the  pharynx  with  scissors,  owin^  to  the  difficulty  which  the  use  of  the 
cautery  creates  in  knowing  wiiether  the  i-equired  depth  has  been  reached  in  the  extir' 
pation  of  the  growth. 

f  Loc.  supra  cit.,  pp.  176,  177, 


344  OPERATIONS  OX  THE  HEAD  AND  NECK. 

(3)  Mickulitz's  Method. 

This  is  intended  to  be  even  more  radical  than  that  of  Czerny.  An 
incision  being  made  from  the  mastoid  process  downwards  and  for- 
wards as  far  as  the  great  cornii  of  the  hyoid,  the  soft  parts  are  raised 
from  the  jaw,  the  facial  nerve  being  preserved  if  possible,  and  the  peri- 
osteum is  separated  from  the  outer  and  inner  aspects  of  the  jaw  just 
above  the  angle.  The  jaw  is  then  sawn  through  beneath  the  perios- 
teum, the  tendon  of  the  temporal  divided,  and  the  ascending  ramus 
resected.  After  drawing  aside,  with  strong  hooks,  the  body  of  the 
jaw,  the  masseter,  internal  pterygoid,  digastric,  and  stylo-hyoid,  Mick- 
ulitz  found  that  the  surface  of  his  wound  corresponded  as  nearly  as 
possible  with  the  region  of  the  tonsil,  and  by  dividing  the  lateral  wall 
of  the  pharynx,  he  obtained  access  to  the  palate,  the  base  of  the 
tongue,  and  the  posterior  wall  of  the  pharynx  as  far  up  as  the  naso- 
pharynx ;  and  by  dividing  the  digastric  muscle  and  the  hypoglossal 
nerve,  he  could  reach  the  entrance  of  the  larynx.  Mickulitz  prefers 
to  do  a  preliminary  tracheotomy,  and  claims  for  his  operation  not 
only  ease  in  reaching  and  removing  the  disease,  and  in  dealing  with 
lymphatic  glands,  but  further,  that  the  whole  wound  communicates 
freely  with  the  outside,  and  can  be  dressed  antiseptically.  So  far  from 
the  resection  of  the  ascending  process  being  a  disadvantage,  it  offers 
the  positive  advantage  of  giving  more  mobility  of  the  jaw  than  is 
otherwise  present  after  the  contraction  of  the  scar  which  takes  place 
after  any  of  these  operations. 

Mickulitz's  patient  was  a  woman,  aged  sixty-five,  and  the  disease 
had  existed  about  four  months.  She  recovered  and  remained  well  for 
two  years,  when  recurrence  appeared  in  the  glands. 


CHAPTER   XII. 


OPERATIONS  ON   THE   AIR  PASSAGES  IN   THE 

NECK. 

THYROTOMY—LARYNGOTOMY— TRACHEOTOMY-RE- 
MOVAL OF  FOREIGN  BODIES  IN  THE  BRONCHI- 
EXCISION  OF  THE  LARYNX. 

THYROTOMY. 
Indications. 

(i)  Growths  which  cannot  be  removed  through  the  mouth,  but 
which  do  not  require  severer  operations  on  the  larynx  itself  The  fol- 
lowing are  the  chief  conditions  which  must  decide  the  removal  of 
laryngeal  growths  by  an  operation  from  the  mouth  or  by  thyrotomy  : 


THYROTOMY.  345 

(a)  The  amount  of  special  laryngeal  skill  possessed  by  the  oper- 

ator. 

(b)  The  nature  of  the  growth,  whether  multiiDle  or  no,  if  peduncu- 

lated, if  recurrent  after  attempts  at  removal  from  the  mouth. 

(c)  The  extent  of  the  growth. 

(cZ)  The  irrital)ility  of  the  larynx.     The  amount  of  self-control  of 
the  patient.     Any  tendency  to  asphyxia. 

(ii)  Large  rough  foreign  bodies*  ^.(7.,  bits  of  bone,  etc.  In  a  case 
brought  before  the  Clinical  Society  f  by  Dr.  Taylor  and  Mr.  Golding 
Bird,  a  bit  of  mutton-bone  was  impacted  between  the  vocal  cords, 
where  it  could  be  seen  with  the  laryngoscope.  It  was  removed  by 
Mr.  Golding  Bird  by  a  vertical  incision  with  its  centre  over  the  cricoid' 
cartilage,  the  crico-thyroid  membrane  being  incised  horizontally.  A 
tracheal  dilator  being  introduced,  the  bone  was  seen  at  once  and  ex- 
tracted with  Toynbee's  ear  forceps.  The  large  size  of  the  fragment, 
its  apparently  firm  position,  the  fact  that  the  broad  surface  and  not 
the  edge  presented,  together  with  its  position  just  at  the  crico-thyroid 
membrane,  led  to  the  external  operation  being  made  use  of. 

Operation. — A  preliminary  laryngotomy  (p.  347)  or  a  high  trache- 
otomy, according  to  the  amount  of  room  required,  having  been  per- 
formed, the  incision  is  prolonged  upwards  and  the  skin  and  fasciae 
over  the  centre  of  the  thyroid  cartilage  are  carefully  divided;  all 
haemorrhage  is  then  arrested  and  the  cartilage  opened  along  its  centre 
with  scrupulous  exactness,  the  thyro-hyoid  and  crico-thyroid  mem- 
branes being  also  divided,  if  needful.  The  halves  being  now  held 
widely  open,  the  foreign  body  is  picked  out  or  the  papillomata  re- 
moved. 

During  the  above  operation  it  may  be  well  to  remember  the  fol- 
lowing points:  If  much  haemorrhage  is  expected,  as  in  the  case  of 
some  papillomata  (if  large  or  recurrent),  it  would  be  well  to  plug  the 
air  passage  below,  by  the  side  of,  and  around  the  tube  which  has  been 
inserted,  either  by  a  sponge  attached  to  silk,  or  by  putting  the  tube 
into  a  collar  of  drainage-tube  of  sufficient  thickness.  The  division  of 
the  thyroid  cartilage  should  be  effected  from  without  inwards,  a  stout 
knife,  bone  forceps,  or  even  a  saw  being  sometimes  needed  in  adults. 
As  soon  as  the  upper  part  is  divided  the  surgeon  should  examine  if 
he  has  sufficient  room  without  further  division,  and  if  it  is  really 
needful  to  cut  down  lower,  the  meeting  of  the  cords  must  be  treated 

*  Mr.  Holqies  {Med  Chir.  Trans.,  1882)  has  drawn  attention  to  the  fact  that  large 
substances  may  be  impacted  in  the  ventricle  or  between  the  alee  of  the  thyroid  carti- 
lage witliout  causing  any  symptoms  of  immediate  urgency.  As  they  are  liable  to  give 
rise  to  spreading  inflammation  of  the  mucous  membrane,  they  should  be  removed  as 
soon  as  possible. 

f  Trans,  vol.  xvii.  p.  214. 


346  OPERATIONS    ON    THE    HEAD    AND    NECK. 

with  the  utmost  delicacy,  and  if  the  parts  have  to  be  opened  out,  as 
little  tension  and  stretching  as  possible  should  be  thrown  upon  this 
spot.* 

The  removal  of  papillomata  is  often  attended  with  much  difficulty 
owing  to  their  friability. f  They  are  best  snipped  away  with  scissors 
curved  on  the  flat,  and  their  bases  touched  with  some  powerful  astrin- 
gent, Mr.  Parker  recommending  chromic  acid. 

The  object  of  the  operation  being  accomplished,  and  all  haemorrhage 
arrested,  the  ala3  of  the  thyroid  are  united  by  one  or  two  points  of 
silver  suture  not  passed  through  the  entire  thickness  of  the  cartilage. 
A  little  iodoform  is  dusted  on,  and  lint  out  of  boracic  acid  (warm  or 
cold,  according  to  the  feelings  of  the  patient)  is  kept  constantly  ap- 
plied. 

The  tracheotomy  tube  must  not  be  removed  till  all  risk  of  intra- 
laryngeal  oedema,  etc.,  has  passed  by,  though  it  may  be  early  replaced 
by  one  of  india-rubber.  The  after  treatment  and  complications  are 
much  as  after  tracheotomy  (p.  356).  Coughing  will  be  especially 
harmful  now. 

Impairment  of  the  voice  is  not  unlikely  to  occur  after  thyrotomy, 
quite  apart  from  any  injury  inflicted  on  the  cords  during  the  opera- 
tion, owing  to  the  cicatrix  subsequently  involving  the  anterior  com- 
missure of  the  cords.  Other  possible  causes,  in  spite  of  aseptic 
precautions  and  gentle  handling,  are  chronic  laryngitis,  the  formation 
of  granulations,  impaired  movement  of  the  thyroid,  or  displacement 
of  the  cords.  Where  the  masses  of  papillomata  are  large,  though  the 
removal  has  been  complete,  the  patient  may  never  be  able  to  dispense 
with  his  tube. 

LARYNGOTOMY. 

In  this  operation  the  tube  is  inserted  through  an  opening  in  the 
crico-thyroid  membrane.  It  is  called  for,  in  preference  to  tracheotomy, 
on  account  of  the  greater  facility  with  which  it  is  performed,  in  cases 
of  emergency,  and  in  those  where  a  tube  can  quickly  be  dispensed 
with.:];     Finally,  it  is  inapplicable  before  adolescence. 

*  Mr.  Parker  {Diet,  of  Surg.,  vol.  ii.  p.  623),  advising  that,  if  it  is  needful  to  cut  the 
anterior  commissure  of  the  cords,  the  two  alse  of  the  thyroid  siiould  not  be  quite 
severed,  points  out  that,  in  children,  the  parts  being  elastic,  retraction  will  accomplish 
much,  but  that  in  old  people,  or  where  the  growth  is  large  or  extensive,  not  only  all 
the  cartilage  and  the  thyro-hyoid  membrane  must  be  divided,  but  that,  to  secure  still 
more  room,  horizontal  incisions  may  be  needed  through  the  crico-thyroid  and  the 
thyro-hyoid  membranes,  close  to  the  borders  of  tiie  cartilages. 

t  Mr.  Parker  (/oc  supra  cit.)  found  in  one  case  much  difficulty  in  seizing  the 
growths,  owing  to  the  reflex  excitability  set  up,  notwitiistunding  deep  narcosis.  He 
thinks  that  the  use  of  cocaine  will  here  be  a  material  aid. 

X  Owing  to  the  proximity  of  the  tube  to  the  cords  this  operation  is  not  suited  to 
cases  in  which  an  instrument  has  to  be  worn  for  any  time. 


LARYNGOTOMY.  347 

Indications. 

1.  Sudden  impaction  of  large  foreign  bodies  threatening  suflPoca- 
tion,  as  when  a  bolus  of  food  carelessly  swallowed  lodges  in  the  upper 
aperture  of  the  larynx.* 

2.  Before  operations  likely  to  be  attended  with  much  bleeding,  e.g., 
those  on  the  tongue,  jaws,  tonsils,  etc.,  in  order  that  the  fauces  may 
be  plugged  with  a  sponge. 

3.  When  spasm  of  the  larynx  is  threatening  very  suddenly,  as  in 
tetanus,  or  aortic  aneurism,!  as  a  rule  tracheotomy,  when  there  is  time 
to  perform  it,  is  preferred  in  these  spasmodic  aflections,  and  it  will  be 
considered  later  (p.  364). 

Operation. — An  anesthetic  will  be  given  in  those  cases  in  which 
laryngotomy  precedes  another  operation ;  in  other  cases  the  patient's 
head  must  be  kept  steady.  In  either  instance  the  head  will  be  thrown 
back  as  far  as  possible,  while  the  neck  rests  on  a  firm  support.  The 
precise  position  of  the  thyroid  and  cricoid  cartilages  is  then  distinctly 
made  out,  the  notch  in  the  upper  part  of  the  former  and  the  ring  of 
the  latter  being  almost  always  recognizable.  The  larynx  being  then 
steadied  (not  squeezed)  with  the  left  fingers  and  thumb,  and  the 
skin  at  the  same  time  made  moderately  tense,  an  incision  about  an 
inch  and  a  half  long  is  made,  exactly  in  the  middle  line,  over  the 
lower  part  of  the  thyroid,  the  crico-thyroid  interval,  and  the 
cricoid. 

If  relief  is  urgently  called  for,  the  knife  should  pass  down  to  the 
crico-thyroid  membrane  at  once,  and  the  left  index  having  identified 
this,  the  membrane  is  opened  by  cutting  horizontally  just  above  the 
cricoid  cartilage. 

If  the  surgeon  have  more  leisure,  he  may  reach  the  crico-thyroid 
membrane  more  gradually,  feeling  his  way,  using  retractors,  and  per- 
haps identifying  the  interval  between  the  sterno-hyoids  and  the  crico- 
thyroids. The  only  advantage  of  this  is  that  all  haemorrhage  can  be 
arrested  before  opening  the  air  tube. 

In  inserting  the  tube,  care  must  be  taken  that  both  the  crico-thyroid 
membrane  and  the  adjacent  mucous  membrane  are  punctured,  and 
that  the  tube  is  really  within  the  cavity  of  the  larynx,  not  pushed 
down  into  the  cellular  tissue  outside  it.  The  cannula,  which  should 
be  shorter  than  those  used  for  tracheotomy,  of  uniform  bore  through- 
out, and  oval  in  section,  is  then  secured  with  tapes. 


*  In  these  very  urgent  cases  the  operation  may  be  performed  with,/aitte  de  mieux,  a 
sharp  |>enknife  and  a  toothpick  quill. 

+  Mr.  Erichsen,  in  his  Surgery,  gives  many  other  conditions  for  which  a  high  tra- 
cheotomy is  usually  reserved. 


348  OPERATIONS   ON    THE    HEAD    AND    NECK. 

TRACHEOTOMY. 

This  operation  will  be  carefully  considered  under  the  first  of  the 
following  indications,  and  more  briefly  in  its  relation  to  the  other 
ones. 

Indications : 

1.  Croup  and  diphtheria. 

2.  Syphilitic  and  tubercular  ulceration,  in  order  to  give  rest  to  the 

crippled  part. 

3.  Malignant  disease  of  the  larynx. 

4.  Acute  laryngitis. 

5.  Certain  spas|nodic  affections — e.g.,  tetanus,  or  aneurism  of  the 
•  thoracic  aorta. 

6.  Foreign  bodies  in  the  air  passages  :  the  removal  of  those  which 

may  lodge  in  the  bronchi  being  treated  separately  (p.  367). 

TRACHEOTOMY    FOR    MEMBRANOUS   LARYNGITIS.* 

General  points  all  bearing  upon  a  successful  result  :t  (A)  The  age 
of  the  patient.  (B)  Right  time  of  operating  and  wise  selection  of 
cases.  (C)  Skilful  operation.  (D)  Painstaking  and  appropriate 
after-treatment. 

A.  Age. — Recovery  before  the  age  of  two  is  very  rare.  Some  of  the 
youngest  cases  recorded  are  IVIr.  Bell's  at  seven  months,  and  Mr. 
Cooper  Forster's  at  eleven  months. J  On  the  other  hand,  M.  Trousseau 
considers  the  frequency  with  which  tracheotomy  is  unsuccessful  in 
adults  with  membranous  laryngitis  is  due  to  the  fact  that  the  large 
size  of  the  larynx  retards  asphyxia  till  the  bronchi  are  invaded. 
Again,  the  older  children  are,  the  more  strength  have  tliey  and  the 
better  the  hope  of  recovery ;  whereas  younger  children  fail  more 
quickly  with  their  poorer  vitality  and  the  greater  facility  with  which 
their  nan*ow  air  passages  are  choked  up  with  membrane,  etc. 

Average  of  Recoveries  after  Tracheotomy  for  Membranous  Laryngitis.% — 

*  Under  this  head  are  inchided  the  two  diseases  whose  identity  is  disputed — croup 
and  diphtheria. 

f  If  a  little  amplified,  the  conditions  chiefly  affecting  success  would  run  somewhat 
thus  :  1.  How  far  has  the  operator  picked  his  cases  ?  2.  What  proportion  was  diph- 
theritic ?  3.  How  many  were  very  young  ?  4.  Was  the  operation  an  early  or  late 
one?     5.  W^as  the  operator  experienced  ?     6.  Was  the  after-treatment  skilled  ? 

X  M.  Bazeau  {Gaz.  des  Hop.,  1867,  p.  397)  mentions  successful  cases  of  tracheotomy 
in  infants  of  ten  and  fifteen  months.  The  very  youngest  cases  with  which  I  am 
acquainted  are  one  in  which  Mr.  Croft  operated  successfully  in  an  infant,  aged  six 
months,  with  erysipelatous  oedema  of  the  neck  and  chest.  One  still  younger  is  quoted 
in  the  ifed.  Times  and  Oaz.,  1880,  vol.  ii.  p.  593. 

§  Turning  to  the  results  of  foreign  surgeons,  Dr.  Lindner  (Dent.  Zeitsch.f.  Chir.,  Bd. 
xvii.  Heft  6)  states  that  after  the  second  year  there  was  a  marked  improvement.     In 


TRACHEOTOMY.  349 

One  case  in  three  or  four  is  a  good  average.  Prof.  Buchanan  *  cured 
nineteen  out  of  fifty,  or  one  in  every  21  cases. 

B.  Right  Time  for  Operating,t  and  Wise  Selection  of 
Cases. — The  nature  of  the  dyspnoea  is  very  various,  and  on  this 
account  the  above  two  points  are  most  important. 

The  four  following  conditions  of  dyspnoea  are  met  with :  (i.)  Dys- 
pnoea rapid,  urgent,  and  localized  to  the  larynx ;  much  anxiety  and 
restlessness ;  orthopnoea ;  stridor,  the  loudness  of  which  is  probably 
proportionate  to  the  degree  of  obstruction  in  the  larynx  and  the  pat- 
ency of  the  small  tubes.  In  Prof.  Buchanan's  words,  it  points  to  a 
cavity  ready  to  receive  air  if  it  could  but  get  it,  and  to  a  passage  nar- 
rowed either  by  false  membrane  or  spasm,  or  both.  On  inspection  of 
chest,  the  extraordinary  muscles  of  respiration  are  seen  to  be  in  a^ction, 
there  is  much  sucking-in  of  infra-costal  and  epigastric,  and,  later  on, 
of  supra-sternal,  and  supra-clavicular  regions.  While  this  sucking-in 
is  vigorous  and  well-marked,  the  lungs  are  probably  free.  Ausculta- 
tion and  percussion  are  difficult.  If  the  bases  are  resonant,  and  show 
vesicular  murmur,  it  is  of  good  omen.  So,  too,  if  the  eyes,  though 
staring,  are  bright,  the  face  suffused,  not  livid,  the  lips  of  fairly  nat- 
ural color,  the  cervical  veins  not  much  distended,  the  extremities  not 
cold  and  the  seat  of  stasis.  In  such  cases  the  membrane,  if  present, 
is  limited  to  the  larynx,  and  the  tendency  to  death  is  by  laryngeal 
apnoea.  Tracheotomy  here  is  not  only  justifiable,  but  imperatively 
called  for,  if  previous  treatment  has  failed  ;  the  prognosis  is  favorable 
if  the  operation  is  not  too  long  deferred.  Hopeful  conditions  :  Sud- 
den onset,  previous  good  health,  sub-maxillary  glands  not  enlarged, 
absence  of  albuminuria. 

this  year  the  recoveries  amounted  to  12  per  cent.,  in  the  third  year  they  rose  to  55 
per  cent.  Dr.  Passavant,  of  Frankfort-on-Main  {Annals  of  Surgery,  vol.  i.  p.  582),  gives 
67  cases  of  cure  out  of  229,  or  about  1  in  4. 

*  Trans.  Inttrn.  Med.  Congr.,  1881,  vol.  iv.  p.  208. 

t  Those  surgeons  who  recommend  an  early  operation,  and  I  am  of  that  number,  rely 
especially  on  the  establishment  of  much  sucking  in  and  of  undoubted  dyspnoea.  With 
regard  to  the  first,  Dr.  Passavant  {he.  supra  cit.,  p.  153)  holds  that  tracheotomy,  if  de- 
ferred, allows  prolonged  dyspnoea  to  bring  about,  simultaneously  with  retraction  of  the 
epigastrium,  etc.,  an  action  on  the  lung-surface  analogous  to  that  of  a  cnpping-glass 
upon  the  skin — viz.,  hypersemia,  stasis,  hyper-secretion  of  mucus,  splenization,  and 
atelectasis.  With  regard  to  dyspnoea,  Dr.  Ranke,  of  Munich,  lays  great  stress  upon 
an  early  operation  :  "  If  a  child  with  pharyngeal  diplitheria  has  become  hoarse,  and 
shows  laryngeal  stridor  and  difSculty  in  breathing,  which  has  already  led  to  ever  so 
short  an  attack  of  real  dyspnoea,  that  child  ought  to  be  operated  upon  at  once." 
Another  practical  point  bearing  upon  the  right  time  for  operation  is  the  fact  tiiat  at 
night-time  children  often  get  worse.  If,  then,  a  case  is  advancing,  and  parents  cannot 
towards  the  day's  close  make  up  their  minds  to  sanction  an  operation,  tliey  may  be 
warned  tliat  the  patient's  condition  may  call  for  an  operation  which  will  be  of  neces- 
sity hurried   and  performed  under  mucii  less  favorable  circumstances  as  to  light,  etc. 


350  OPERATIONS   ON   THE   HEAD   AND   NECK. 

(ii.)  When  the  dyspnoea  increases  more  slowly  though  continu- 
ously. The  restlessness  is  less  violent,  and  the  respiratory  effects  less 
exaggerated.  The  sucking-in  is  much  less  marked,  especially  above. 
The  chest  seems  to  be  impeded  in  its  movements,  puffing  or  heaving 
out  en  masse,  and  with  difficulty ;  on  auscultation  and  percussion, 
instead  of  vesicular  murmurs,  or  conducted  hoarse  laryngeal  rhonchus, 
and  normal  bases,  will  be  found  sibilant  rales,  small  crepitation,  and 
deficient  resonance.  These  point  to  the  exudation  being  no  longer 
localized  to  the  larynx,  but  more  probably  invading  the  finer  bron- 
chial tubes  and  air-vesicles,  the  former  being  swollen  and  infiltrated 
with  membrane,  the  latter  clogged  with  viscid  mucus.  The  tint  of  the 
face  is  now  pale  or  leaden.  The  operation  is  here  much  less  likely  to 
be  successful,  from  the  extension  of  the  membrane,  the  condition  of 
the  lung  and  of  the  right  heart.  Other  unfavorable  conditions  : 
Onset  with  much  asthenia,  albuminuria  and  enlarged  sub-maxillary 
glands. 

(iii.  and  iv.)  Dyspnoea  intermittent  or  paroxysmal.  In  the  former 
case  it  is  due  probably  to  collections  of  viscid  mucus  or  membrane  in 
the  larynx  and  trachea.  Good  power  of  expectoration  is  here  very 
important.  Paroxysmal  dyspnoea  means  spasm.  This,  very  common 
in  all  laryngeal  dyspnoea,  is  especially  so  in  children.  The  danger  of 
this  is  obvious,  and  the  question  of  tracheotomy  will  have  to  be 
decided  according  to  whether  the  spasms  are  increasing,  and  by  the 
distance  of  the  medical  man  from  his  patient. 

Three  chief  dangers  of  deferring  the  operation  too  long. 

(1.)  CEdema  of  the  lungs.*  Owing  to  the  deficient  entrance  of  air, 
reflex  contraction  of  the  pulmonary  arterioles  takes  place,  leading  to 
distention  of  the  main  trunk,  the  right  heart,  and  systemic  veins. 
The  bronchial  veins  being  also  engorged,  serous  exudation  takes  place 
into  the  finer  tubes  and  vesicles  at  the  bases,  and  respiration  is  thus 
further  impeded. 

(2.)  Thrombosis  of  pulmonary  artery.  Owing  to  the  stagnation  in 
front,  the  blood  current  moves  more  and  more  slowly,  and  this 
obstruction  by  thrombi  is  not  remediable  by  operation.  The  signs  of 
this  condition  are,  increasing  dyspnoea,  very  feeble  pulse,  and  com- 
bined pallor  and  lividity. 

(3.)  Exhaustion  of  heart.  Children  if  they  repair  quickly  are 
exhausted  quickly  also.f 

Recommendation  of  the  operation  to  the  friends. — (a)  In  reply  to  ques- 


*  See  also  the  note,  p.  349. 

f  Prof.  Buchanan  {loc.  supra  cit.,  p.  208)  makes  an  important  distinction  between 
sthenic  and  asthenic  cases.  In  the  latter,  where  the  vital  powers  are  rapidly  failing, 
tracheotomy  will  not  save  the  patient,  and  scarcely,  if  at  all,  mitigates  the  suffering. 


TRACHEOTOMY.  351 

tions  as  to  the  chance  of  cure,  the  surgeon  will  answer,  with  caution, 
that  the  operation  conduces  to  cure  by  removing  the  most  urgent 
danger,  by  giving  relief  to  the  lungs,  and  thus  also  improving  the 
strength  by  sleep  and  quiet.  (/5)  He  will  be  able  to  say  that  if  death 
occur  after  tracheotomy  it  will  be  by  exhaustion,  not  by  apnoea  most 
distressing  to  witnesses  as  well  as  to  the  patient. 

Operation. 

Question  of  Ansesthetic. — A  little*  chloroform  is,  as  a  rule,  safe 
and  advantageous.  It  allays  spasm  and  thus  improves  the  breathing. 
It  prevents  struggles  and  promotes  sleep  afterwards.  Any  vomiting 
afterwards  will  probably  be  beneficial.  It  is  especially  useful  in 
recent  and  vigorous  cases,  where  the  surgeon  is  very  short  of  assist- 
ance, and  where,  if  I  may  say  so,  his  practical  experience  of  the 
operation  is  not  large.  Under  the  opposite  conditions  it  is  not  needed ; 
and  it  will,  of  course,  not  be  given  where  there  is  any  tendency  to 
C3\anosis  and  unconsciousness. 

Site  of  Operation. — High  or  low,  i.e.,  above  or  below  the  isthmus. 
It  will  be  worth  while  just  to  consider  here  the  parts  met  within  the 
middle  line,  (A)  above,  and  (B)  beloAV,  the  thyroid  isthmus.  (A)  Skin, 
superficial  fascia,  branches  of  transverse  cervical  and  infra-maxillary 
(7th)  nerves,  iymphatics,  cutaneous  arteries,  anterior  jugular  veins — 
which,  with  their  transverse  branches,  are  smaller  here — deep  fascia, 
cellular  tissue,  superior  thyroid  vessels,  the  isthmus,  usually  over  the 
second  and  third  rings,!  ^^^^  tracheal  layer  of  deep  fascia.  The  im- 
portance of  this  last  is  twofold,  if  the  trachea  be  insufficiently  opened 
the  tube  may  be  passed  between  the  trachea  and  the  fascia  overlying 
it,  embarrassing  the  breathing  and  the  operator  alike.  If  the  wound 
become  unhealthy,  this  layer,  continuous  below  with  the  pericardium, 
may  conduct  pus  into  the  mediastina.  (B)  The  surface-structures  are 
much  the  same,  but  the  anterior  jugular  vein  and  its  transverse 
branches  are  much  larger.  The  sterno-thyroids  are  here  X  quite  close 
together.  The  inferior  thyroid  veins  are  larger.  A  thyroidea  ima 
may  be  present,  and  the  innominate  artery  cross  as  high  as  the  seventh 
ring.  The  trachea  is  also  deeper,  smaller,  and  more  mobile,  having 
no  steadying  muscles  here  as  higher  up.  The  thymus,  too,  in  young 
children,  might  present  a  difficulty.  In  addition  to  the  above  anatom- 
ical objections  to  the  low  operation,  there  are  three  surgical  ones,  viz.: 

*  Just  enough  to  prevent  struggling  during  the  operation.  After  the  skin  is  incised, 
less  is  needed. 

t  Mr.  Parker  {Tracheotomy,  p.  37)  says  that  in  children  the  isthmus  is  almost  always 
higher  up,  generally  on  the  crico-tracheal  membrane  and  the  first  tracheal  ring. 

X  Above,  the  sterno-hyoids  are  almost  in  contact  in  the  middle  line,  with  only  an 
interval  of  about  J  inch,  a  strong  argument  in  favor  of  keeping  in  the  middle  line 
exactly  (Parker). 


352  OPERATIONS   ON   THE    HEAD   AND   NECK. 

(1)  Pus  is  now  more  easily  conducted  into  the  mediastina.  (2)  In 
the  same  way  broncho-pneumonia  is  more  probable  from  a  wound  in 
the  trachea  low^er  down.  (3)  From  the  proximity  of  the  chest,  and 
its  suction-action,  the  tube  is  much  more  pulled  into  the  wound,  and 
if  it  has  to  be  worn  for  a  long  time,  the  tube  and  shield  may  part 
company.* 

Operation. — The  instruments  required  are — a  small  scalpel,  with 
a  triangular-pointed  handle  to  act  as  a  blunt  dissector,  two  pairs  of 
Spencer  Wells's  forceps,  dissecting  forceps,  steel  director,  silk  or  chromic 
gut  ligatures,  one  or  two  wire  sutures,  pilot  and  tube.f  The  question 
of  the  anaesthetic  has  already  been  alluded  to  (p.  351).  The  child's 
neck  and  head,  at  first  raised  and  relaxed, :|:  are  stretched  over  a  sand- 
bag or  a  large  bottle  wrapped  up  in  a  towel,  while  the  hands  are 
secured  in  the  jack-towel  which  firmly  encircles  the  body.  Two 
assistants  are  desirable,  one  to  support  the  head  and  give  the  an£esthetic, 
the  other  to  sponge.  It  is  almost  superfluous  to  add  that  the  light 
should  be  the  best  possible,  a  laryngeal  mirror  may  be  of  much  use 
in  illuminating  the  bottom  of  the  wound.  The  surgeon  §  with  his 
left  thumb  and  forefinger  steadies  the  trachea,  and  makes  it  a  little 
prominent  as  well,  without  any  compression  ;  he  then  incises  the  soft 

*  Mr.  J.  Wood,  Lancet,  1872,  vol.  i.  p  317. 

f  The  best  tracheotomy  tubes  are  those  of  Mr.  Durliam,  Mr.  Bryant,  and  Mr. 
Parker.  If  the  first  are  chosen  they  must  be  of  reliable  manufoctiire.  The  ball-and- 
socket  of  Mr.  Bryant's  tubes  allows  of  free  play.  Mr.  Parker  (loc.  supra  cil.,  p.  42) 
argues  strongly  in  favor  of  angular  tubes.  He  shows  that  the  usual  ^-inch  tubes  im- 
pinge with  their  lower  extremity  on  the  anterior  wall  of  the  trachea,  thus  tending  to 
produce  ulceration  and  grave  risks  (p.  361).  Mr.  Parker,  I  think,  entirely  proves  his 
point.  I  have  used  his  tubes,  but  find  the  absence  of  a  pilot  troublesome  in  dealing 
with  little  children. 

Whatever  tube  is  chosen,  it  should  be  as  large  and  as  short  as  possible;  it  should  be 
of  the  same  size  throughout,  without  tapering;  the  inner  tube  should  project  a  little 
beyond  the  outer  one;  while  the  whole  tube  should  fit  snugly,  standing  out  as  little  as 
possible  in  the  neck. 

As  to  the  size  of  the  tubes  needful,  Mr.  Parker  recommends  a  series  running  from 
Jvo.  18  to  No.  30,  French  gauge,  the  most  useful  sizes  for  children  being  Nos.  18,  20, 
22,  24,  26,  and  28  for  the  outside  tube.  On  this  matter  of  the  size  of  the  tube  and  its 
relation  to  the  aperture  of  the  glottis  and  size  of  the  air-tube,  the  reader  should  con- 
sult Mr.  Holmes  {Dis.  of  Children,  p.  324),  Mr.  Howse  (Guy's  Hosp.  Reports,  1875,  p. 
495),  and  Mr.  Marsh  [St.Barlhol.  Hosp.  Reports,  vol.  iii.). 

X  Whenever  an  ansesthetic  is  being  given  in  cases  of  dyspnoea,  the  patients,  whatever 
the  age,  should  be  allowed  to  choose  their  own  position  at  first,  and  any  movements  or 
alterations  in  the  position  of  the  head  and  neck,  preparatory  to  the  commencement  of 
the  operation,  should  be  carefully  made. 

§  He  first,  as  soon  as  the  head  and  neck  are  in  position,  marks  the  chief  spots  in  the 
middle  line — viz.,  centre  of  the  chin  and  manubrium,  and  (when  they  can  be  felt)  the 
hyoid  bone  and  the  thyroid  and  cricoid  cartilages,  especially  the  last. 


TRACHEOTOMY.  353 

parts  in  the  middle  line  from  about  the  centre  of  the  cricoid  *  down- 
wards for  about  two  inches,  cutting  well  through  the  fat,  often  abun- 
dant here,  and  exposing  the  interval  between  the  sterno-hyoids,  he 
then  incises  this  interval,  and,  if  he  has  reason  to  fear  haemorrhage, 
with  the  point  of  a  steel  director  f  placed  in  the  upper  part  of  the 
wound  he  slits  down  the  remaining  soft  parts  in  the  middle  line  till 
he  can  distinctly  feel  or,  with  the  aid  of  retractors,  see  the  tracheal 
rings4  The  point  of  the  knife  is  often  required  here  to  incise  surely 
the  tracheal  fascia.  Until  the  tube  is  distinctly  exposed  the  left  fore- 
finger and  thumb  must  not  be  removed  from  their  steadying  position 
on  either  side.  With  the  blade  of  the  knife  held  upwards  the  middle 
line  of  the  front  of  the  trachea  is  then  punctured,  stabwise,  and  two 
or  three  rings  divided.  Sufficiency  of  the  opening  is  known  by  a  free 
and  noisy  rush  of  air,  accompanied  often  by  the  expulsion  of  mem- 
brane, which  should  be  sponged  away  at  once.  On  the  other  hand  an 
inadequate  opening  will  be  indicated  by  the  hissing  only  of  air  through 
the  slit-like  opening,  without  any  free  rush  and  with  no  escape  of  the 
membrane  or  relief  of  the  dyspnoea.  In  this  latter  case  the  first  opening 
must  be  found  by  the  finger-nail  and  carefully  enlarged. §  The  can- 
nula is  then  inserted  on  a  pilot  and  secured  with  tapes  in  situ.  Some 
prefer  to  use  a  pair  of  dressing-forceps  to  dilate  the  opening,  but  this 
is  not  necessary  in  the  high  operation,  when  the  tracheal  opening  has 
been  rightly  made  both  as  to  size  and  site,  and  Avhen  a  pilot  is  used  to 
introduce  the  cannula.  If  it  be  desired  to  try  and  remove  any  mem- 
brane,! |  the  cannula  should  not  be  inserted  at  once,  but  the  opening 

*  This  cartilage  is  often  incised,  a  point  to  be,  liowever,  avoided.  The  parts  are  so 
small  in  a  child  that  a  tuhe  put  in  by  incising  the  cricoid  is  likely  to  irritate  the  larynx. 
Of  this  the  cricoid  is  the  narrowest  and  a  very  rigid  part.  Only  the  smallest  cannulfe 
can  be  used  here. 

f  Mr.  Whitehead  {Lancet,  April  30,  18S7),  having  found  that  the  sharp  point  of  a 
director  will  tear  open  the  thin-walled  veins  here,  uses  a  raspatory  after  the  skin  inci- 
sion. With  this  he  separates  the  sterno-hyoids,  splits  the  fascia  running  from  the  hyoid 
to  the  thyroid  isthmus,  and  then,  pushing  this  split  fascia  on  either  side  with  the  raspa- 
tory, pulls  down  the  isthmus  and  exposes  the  trachea,  the  whole  operation  being  thus 
rendered  easy  and  bloodless. 

X  Dr.  Buchanan  considers  the  following  a  golden  rule  :  "  Never  plunge  the  knife  into 
the  trachea  till  the  white  rings  are  clearly  seen  in  the  bottom  of  the  wound."  In  cases 
of  real  urgency  the  surgeon  must  be  satisfied  witli  touch  and  not  with  sigiit. 

§  If  the  opening  be  to  one  side,  as  well  as  too  small,  a  fresh  and  adequate  one  should 
be  made  in  the  middle  line. 

II  Mr.  Parker,  one  of  the  chief  authorities  on  this  subject,  strongly  advises  that  all 
membrane  as  well  as  mucus  be  got  rid  of,  on  account  of  its  impediment  to  respiration, 
its  infectiousness,  and  the  patient's  inability  to  get  rid  of  it  himself  by  coughing  after 
tracheotomy.  On  this  account  Mr.  Parker  recommends  gently  twirling  about  a  feather, 
soaked  in  solution  of  sodium  carbonate,  and  passed  several  times,  not  only  down  into 
the  trachea,  but  up  into  the  glottis.     Mr.  Parker  condemns  attempts  to  suck  out  niem- 

23 


354  OPERATIONS   ON    THE    HEAD    AND   NECK. 

dilated  with  dressing-forceps,  or  with  Mr.  Go] ding  Bird's  or  Mr. 
Parker's  dilator.  When  inserted,  the  cannula  must  lie  in  the  middle 
line,  otherwise  there  will  be  troublesome  irritation  of  the  trachea  and 
plugging  of  the  cannula. 

Chief  Difficulties. — (1)  Insufficient  skin  incision  giving  no  room  for 
the  deeper  work.*  (2)  Not  keeping  the  middle  line,  the  abundant  fat, 
and  the  indistinctness  of  landmarks — e.g.,  a  flat  thyroid  in  a  little  child 
aiding  this  mistake.  (3)  Not  steadying  the  trachea.  This  omission 
leads  to  missing  the  tube  altogether.  Cutting  to  one  side  of  it,  or 
cutting  into  it  laterally  instead  of  centrally,  and  insufficiently.  (4) 
Hemorrhage,  the  chief  bugbear  of  the  operation,  varies  extremely. 
Generally  it  is  not  great.  Any  artery  which  springs  should  of  course 
be  tied  at  once  or  caught  in  Spencer  Wells's  forceps,  and  a  vein  of  any 
size  which  lies  in  the  way  should  be  caught  between  two  of  these  for- 
ceps before  it  is  divided.  Venous  hemorrhage,  as  a  rule,  stops  as  soon 
as  the  trachea  is  opened  and  respiration  established.  A  sufficient 
median  skin  incision  aids  the  meeting  of  haemorrhage.  With  regard 
to  the  isthmus  of  the  thyroid,  this  may  usually  be  neglected  by  the 
surgeon  ;  if  felt  with  the  finger  to  be  large  it  may  be  depressed. f  If 
encountered  in  older  subjects,  or  if  large  in  children,  it  may  be  com- 
pressed by  two  pairs  of  Spencer  Wells's  forceps  before  division,  or  liga- 
tured on  either  side  by  passing  an  aneurism-needle  beneath  it.  If,  as 
very  rarely  happens,  the  venous  bleeding  is  very  free,  and  the  patient's 
condition  from  dyspnoea  critical,  the  trachea  must  be  felt  for  and 
opened  before  the  haemorrhage  is  arrested.  The  urgency  of  the  case 
must  here  come  before  the  amount  of  the  bleeding.  In  these  cases  the 
moment  the  tube  is  opened  the  patient  must  be  turned  well  over  on  to 
his  side.  Entrance  of  blood,  to  any  amount,  into  the  lungs,  must  be 
avoided,  as  not  altogether  harmless ;  it  will  add  to  the  dyspnoea  now, 
and  later  on,  may  set  up  broncho-pneumonia.  (5)  Insertion  of  can- 
nula. If  the  trachea  has  not  been  steadied,  and  the  rings  not  clearly 
made  out  by  sight  or  touch,  the  opening  will  very  likely  be  made  in- 
adequate, or  to  one  side.  Another  difficulty  may  arise  here  from  the 
tracheal  fascia  not  having  been  sufficiently  cut,  or  from  the  tube  being 
pushed  down  between  this  fascia  and  the  trachea,  this,  of  course,  only 
further  embarrassing  the  breathing.  Lastly,  though  the  tracheal  rings 
are  cut,  the  swollen  and  inflamed  mucous  membrane  may  not  have 

brane  by  putting  the  lips  directly  to  the  wound,  as  of  no  service  to  the  patient,  and  as 
possibly  very  disastrous  to  the  operator. 

*  As  in  a  colotomy,  or  any  other  deep  incision,  the  wound  should  not  lie  funnel- 
shaped  . 

f  In  cliildren  this  may  certainly  be  ignored.  If  the  knife  is  used  to  open  cleanly 
and  sufficiently  the  deep  fascia,  and  then  a  fine-pointed  steel  director  to  clear  the  way 
down  to  the  trachea,  the  operation  will  be  almost  bloodless. 


TEACHEOTOMY.  355 

been  sufficiently  divided,  or  a  false  membrane  may  bave,  in  tbe  same 
way,  been  carried  before  tbe  knife.  (6)  Little  or  no  relief  after  inser- 
tion of  the  cannula.  Tbough  tbis  may  have  been  well  and  truly  done, 
it  is  not  followed  by  tbe  relief  which  has  been  expected.  This  may 
be  due  (a)  to  the  tube  being  passed  between  the  trachea  and  some 
membrane  which  plugs  it;  (6)  to  the  trachea  and  bronchi  being 
blocked  with  membrane,  etc. ;  (c)  to  the  child,  owing  to  the  operation 
being  performed  late,  being  practically  asphyxiated  before  the  com- 
pletion of  the  operation.  Tbe  indications  now  are  to  remove  the  tube 
and  to  clear  out  the  trachea,  while  artificial  respiration  is  vigorously 
performed  and  kept  up,  the  opening  into  the  trachea  being  kept  patent 
by  dressing-forceps  or  by  one  of  the  retractors  above  mentioned  (p.  354). 
If  feathers  or  brushes  fail  to  reach  and  remove  the  membrane,  trial 
may  be  made  of  aspiration  by  the  mouth.  The  best  means  of  effecting 
this  is  by  Mr.  Parker's  tracheal  aspirator,*  which  consists  of  a  small 
glass  cylinder,  3  or  4  inches  long,  to'one  end  of  which  the  end  of  a  silk 
catheter  is  attached,  and  to  tbe  other  an  india-rubber  tube  ending  in 
a  mouthpiece.  It  can  be  taken  to  pieces  to  facilitate  cleaning.  Before 
use  a  little  cotton  wool  is  jiacked  into  the  cylinder  to  prevent  any  dan- 
gerous membrane  reaching  tbe  operator's  mouth.  Direct  suction  should 
never  be  performed  in  membranous  laryngitis  ;  where  blood  alone  is 
the  cause  of  the  dyspnoea,  it  may  of  course  be  thus  removed. 

Before  leaving  the  subject  of  operation,  one  or  two  other  methods 
may  be  briefly  alluded  to. 

Method  of  Bose.f — This  is  largely  made  use  of  in  Germany,  as  it  is 
thought  to  do  away  with  those  dangers  which  a  large  thyroid  isthmus 
may  present  in  the  high  operation.  An  incision  is  made  vertically  in 
the  middle  line  for  about  IJ  to  2  inches  from  the  centre  of  the  thyroid 
cartilage.  The  cricoid  being  exposed,  a  transverse  incision  is  made 
along  its  upper  border  so  as  to  divide  the  layer  of  deep  cervical  fascia 
by  which  the  isthmus  is  tied  down.  A  director  or  blunt  dissector  is 
then  introduced  through  this  incision,  and  the  fascia  and  the  isthmus 
with  its  veins  displaced  from  the  trachea  and  depressed.  The  upper 
rings  are  thus  exposed  bloodlessly.  I  have  no  experience  of  tbis  opera- 
tion, but  it  would  appear  not  unlikely  that  even  if  this  layer  of  fascia 
were  quickly  hit  off  and  detached,  this  additional  transverse  incision 
and  separation  of  soft  jjarts  might  lead  to  cellulitis. 

Tracheotomy  by  the  Cautery. — This  method,  used  of  late  in  Germany 
and  France,t  ^^^s  found  very  little  favor  in  England.  It  is  best  per- 
formed by  Paquelin's  thermo-cautery,  used  with  a  series  of  light 
touches.     Owing  to  its  toughness  the  skin  should  be  divided  with  a 

*  Loe.  supra  cit.,  Fig.  10,  p.  53. 

t  Arch.f.  Klin.  Chir.,  Bd.  xiv.  s.  137,  144;  Brit.  Med.  Journ.,  1878,  vol.  i.  p.  572. 

X  Poinset,  Track,  par  k  Thermo- Cauth-e.    Paris:  1878. 


356  OPERATIONS    ON    THE    HEAD    AND    NECK. 

knife,  and  when  the  trachea  is  exposed  this  should  be  opened  in  the 
usual  way.  This  method  has  no  bond  fide  advantages.  Fatal  hemor- 
rhage has  followed  its  use.  The  relations  of  parts  are  much  altered. 
The  heated  condition  of  the  soft  parts  is  most  unpleasant  to  the  finger 
as  it  feels  its  way  before  each  apj)lication  of  the  blade. 

After-treatment. 

This  subject,  neglected  in  most  books,  is  often  too  little  looked  to  in 
practice.  The  question  of  the  most  suitable  atmosphere  for  the  pa- 
tient will  first  arise.  By  most  a  tent  (readily  improvised  by  convert- 
ing a  cot  into  a  four-poster,  by  fastening  on  four  vertical  pieces  of 
wood  at  the  corners,  joining  these  by  four  horizontal  pieces,  and 
throwing  a  sheet  over  all)  is  recommended,  and,  one  side  of  the  cot 
being  left  uncovered,  steam  is  conducted  thither  by  one  of  the  dif- 
ferent forms'  of  croup-kettles.  While  fully  aware  of  the  need  of 
moisture  when  the  atmosphere  is  dry,  when  the  membrane  tends  to 
crust  and  become  fixed,  I  am  of  the  opinion  that  the  above  unvary- 
ing rule  of  cot-tenting  and  use  of  steam  is  disadvantageous.  The 
weakly  condition  of  children  with  membranous  laryngitis,  and  all 
that  they  have  gone  through,  must  be  remembered.  Believing  that 
such  seclusion  and  so  little  admission  of  air  tend  to  increase  the 
asthenia,  and  any  tendency  to  sepsis,  I  much  prefer  to  be  content 
to  keep  off  draughts  by  a  screen,  which  allows  of  the  escape  of  vitiated 
air  above,  using  steam,  if  needful,  according  to  the  size  of  the  room, 
fireplace,  etc.,  and  according  to  the  kind  of  expectoration,  whether 
easily  brought  up  by  cough  or  feathers,  or  viscid,  quickly  drying,  and 
causing  whistling  breathing.  If  the  temperature  can  be  otherwise 
kept  up  to  60°  or  65°,  I  much  prefer  to  use  a  thin  flat  sponge,  often 
wrung  out  of  a  warm  solution  of  boracic  acid.  The  inner  tube  must 
be  frequently  removed  and  cleansed,  every  hour  or  two  at  first.  If 
the  secretions  dry  on  and  cling  to  it,  they  are  best  removed  by  the 
soda  solution  mentioned  below.  At  varying  intervals  between  the 
removal  of  the  tube  any  membrane,  etc.,  which  is  blocking  it,  appear- 
ing for  a  moment  at  its  mouth  and  then  sucked  back,  must  be  got  rid 
of  by  inserting  narrow  pheasant  feathers  and  twisting  them  round 
before  removing  them.  If  the  exudation  is  slight,  moist,  and  easily 
brought  up  by  cough  or  feather,  sponging  and  brushing  out  the  trachea 
are  not  called  for,  but  they  should  be  made  use  of  when  there  is  much 
flapping,  clicking,  or  whistling  of  the  breathing,  and  if  this  is  harsh, 
dry  or  noisy,  instead  of  moist  and  noiseless,  two  of  the  best  solutions 
are  sodse  bicarb.,  gr.  v-xx  to  aq.  Jj,  or  a  saturated  one  of  borax  with 
soda.  These  may  be  applied  by  a  hand  or  steam  spray  over  the  can- 
nula for  five  or  ten  minutes  at  a  time,  at  intervals  varying  according 
to  the  relief  which  is  given,  or  applied  with  a  laryngeal  brush,  feather. 


TRACHEOTOMY.  357 

or  a  bit  of  sponge  twisted  securely  into  a  loop  of  wire.  When  any  of 
these  are  used,  the  risk  of  excoriation  and  bleeding,  and  the  fact  that 
only  the  trachea  and  large  bronchi  can  be  cleaned,  must  be  borne  in 
mind,  and  with  regard  to  manipulations  for  cleansing  the  trachea,  and 
removing  the  inner  tube,  it  is  most  important  to  remember  that  the 
caretaking  may  be  overdone,  and  a  weakly  child  still  further  exhausted 
by  meddlesome  interference.  This  point  requires  especial  attention 
from  the  surgeon  in  the  case  of  some  of  the  nurses  of  the  present  day, 
who  seem  to  wish  to  transfer  the  entire  charge  of  the  case  into  their 
own  hands. 

There  is  often  much  difficulty  in  getting  sufficient  food  taken.  The 
pain  in  swallowing,  the  impairment  of  the  act,  owing  to  the  presence 
of  the  tube,  etc.,  and  thus  the  facility  with  which  liquids  may  reach 
the  lungs,  the  need  of  waking  up  the  child  frequently  to  give  it  food, 
are  all  facts  to  be  duly  remembered.  It  will  usually  be  better  to  pass 
a  Jaques'  catheter  (No.  4  or  6)  by  the  nose,  and  then  to  feed  the  pa- 
tient, at  regular  intervals,  with  definite  amounts.  Care  must  be  taken 
to  see,  by  the  absence  of  irritation,  that  the  tube  is  not  in  the  pharynx, 
and,  if  the  above  soft  tubes  are  used,  that  they  do  not  coil  up  at  the 
back  of  the  tongue. 

The  removal  of  the  tube  next  requires  consideration.  It 
should  be  dispensed  with  at  the  earliest  possible  opportunity,  either 
altogether,  or  rei3laced  by  an  india-rubber  tube  between  the  fourth 
and  ninth  days.  Quite  apart  from  the  danger,  which  is  inseparable 
from  a  metallic  tube,  of  irritation  and  ulceration  of  the  trachea,  there 
is  this  object  in  getting  rid  of  the  tube  as  soon  as  possible,  that  the 
longer  the  child  is  allowed  to  breathe  through  the  tube  the  more  is 
the  act  of  breathing  through  the  natural  passages  allowed  to  be,  as  it 
were,  forgotten,  with  the  result  that,  en  the  tube  being  removed,  as- 
phyxia is.threatened. 

Conditions  which  Impede  the  Removal  of  the  Tube. — (1)  Prolonged  for- 
mation of  membrane.  The  longest  possible  period  for  this  is  proba- 
bly about  ten  days.  Patience  and  support  are  the  main  indications 
in  the  treatment  here.  (2)  The  larynx  is  crippled  like  any  other  in- 
flamed part.  (3)  The  air-tube  is  closed  by  granulations,  usually  above 
the  cannula.  Here  the  tube  must  be  removed,  and  astringents  and 
caustics  carefully  applied  from  below,  with  the  aid  of  an  anaesthetic 
if  necessary.  (4)  Closure  of  larynx  by  deep  ulceration  cicatrizing 
after  detachment  of  membrane.  In  such  a  case,  with  the  aid  of  anaes- 
thetics, the  larynx  must  be  opened  up  by  probes  of  increasing  size 
and  laminaria  tents  introduced  from  below,  and  later  on  by  the  use  of 
Macewen's  tubes  (p.  359).  (5)  Paralysis  of  the  dilating  crico-aryte- 
noidei  postici,  or  spasmodic  action  of  the  closing  ones,  arytenoidei  or 


358  OPERATIONS    ON    THE    HEAD    AND    NECK. 

crico-arytenoiclei  laterales,  from  fear,  excitement,  or  during  effort.* 
The  commonest  cause  of  inability  to  dispense  with  the  tube  is  proba- 
bly due  to  the  rapidity  with  which  the  larynx  falls  into  abeyance 
Avhen  a  child  is  allowed  to  breathe  through  a  tracheal  cannula,  the 
patient  at  this  age  being  not  intelligent  enough  to  understand  the  im- 
portance of  dispensing  with  the  tube,  being  perhaps  too  young  to  care 
to  talk,  and,  if  older,  not  realizing  the  need  of  again  using  its  voice 
while  all  its  wants  are  supplied.  With  the  above  condition  often  goes 
a  nervous  dread  of  having  the  tube  removed,  and  paroxysms  of 
temper  and  struggling  which  rapidly  produce  embarrassed  breathing. 
Any  organic  mischief,  such  as  adhesions  in  the  larynx,  are,  I  think, 
extremely  rare,  and  granulations  above  or  below  the  tube  are  more 
often  talked  of  and  given  as  a  reason  for  inability  to  dispense  with 
the  tube  than  really  seen. 

But  while  real  organic  mischief  is  rare  and  the  usual  cause  is  due 
to  conditions  which  w^ould  seem  to  be  only  temporary,  it  is  well 
known  that,  in  some  cases,  getting  a  little  child  to  dispense  with  the 
tube  is  a  most  baffling  and  prolonged  affair.  The  following  points  are 
worthy  of  attention.  Early  attempts  to  remove  the  cannula,  whether 
metal  or  india-rubber.  A  reliable  nurse,  ability  on  the  part  of  the 
surgeon  so  to  arrange  his  time  as  to  be  himself  frequentl}'  present  at 
first,  and  in  the  intervals  to  be  represented  by  an  assistant  who  will 
not  replace  the  tube  before  it  is  absolutely  necessary  to  do  so,  and 
who  can  dilate  the  opening  with  a  pair  of  dressing-forceps,  and  per- 
form artificial  respiration  if  these  steps  are  required.  Shortening  the 
ipdia-rubber  tube,  till  eventually  little  more  than  the  shield  is  worn, 
the  child  being  comforted  by  the  apparent  presence  of  the  tube.  En- 
couraging the  child  to  make  use  of  his  larynx  by  breathing  through 
the  tube  and  expiring  through  the  larynx  while  the  tube  is  closed. 
Patiently  persevering  efforts  to  get  a  child  to  talk,  or  in  the,  case  of  a 
younger  one  to  use  his  larynx  by  blowing  out  a  spirit-lamp  or  using 
a  penny  trumpet.f 

All  this  time  every  attempt  should  be  made  to  improve  the  general 
health.  Wise  feeding — too  frequent  or  too  large  meals  provoke 
dyspnoea — attention  to  the  bowels,  such  tonics  as  Easton's  syrup, 
proper  clothing,  cold  or  tepid  sponging  followed  by  friction,  change  of 
scene  and  air  in  every  possible  way,  especially  to  the  seaside. 

*  In  a  case  in  which  I  had  performed  tracheotomy,  and  was  watching  the  child  for 

the  first  few  liours  after  the  tube  had  been  dispensed  with,  most  urgent  symptoms  came 
on  during  the  slight  straining  which  accompanied  an  action  of  the  bowels,  tlie  child 
falling  ofl"  from  the  night-stool  on  to  the  floor  apparently  lifeless.  Artificial  respira- 
tion restored  the  child,  and  the  case  did  well. 

f  I  may  advise  my  readers  to  consult  a  most  practical  paper  by  Dr.  Steavenson  {St. 
Barthol.  Hasp.  Reports,  1881). 


TRACHEOTOMY.  359 

In  a  large  majority  of  cases  the  above  treatment,  aided  by  patience, 
tact,  and  time,  which  allows  of  development  of  the  air-passages,  will 
suffice.  In  a  few,  the  attempts  at  removing  the  tube  will  still  fail. 
Where  this  is  so,  and  in  fact  in  any  case  where  the  use  of  the  tube 
seems  likely  to  be  protracted,  the  larynx  should  be  dilated — a  step 
which  is  brought  about  by  simple  means,  as  the  larynx  is  merely  func- 
tionless  from  disuse,  not  blocked  up,  or  the  glottis  closed — by  a  tube 
through  which  the  child  is  made  to  breathe. 

In  a  recent  case  the  simplest  way  of  effecting  this  is,  after  chloroform 
has  been  given,  to  remove  the  tracheotomy  tube,  dilate  the  wound  if 
needful,  and  pass  upwards  from  it  a  drainage-tube  or  catheter  with  a 
double-silk  web  ;  the  upper  end  of  this  is  drawn  out  of  the  mouth 
(with  the  aid  of  a  gag  if  needful),  and  tied  to  the  lower  end  which 
projects  through  the  wound.  The  tracheotomy  tube  is  then  replaced 
for  a  day  or  two,  and  on  the  withdrawal  of  the  tube  from  the  larynx 
it  can  usually  be  dispensed  with  altogether. 

In  cases  of  longer  standing  the  above  simple  treatment  may  not  be 
sufficient,  and  here  the  use  of  Macewen's  tubes  passed  through  the 
larynx*  and  into  the  trachea  below  the  wound  should  be  made  use  of. 
Chloroform  being  given,  one  of  the  above  tubes — they  resemble  stout 
gum-elastic  catheters  with  terminal  carefully  bevelled  openings — is 
passed  from  the  tracheal  opening!  up  through  the  larynx  into  the 
mouth.  Having  hooked  this  end  out  of  the  mouth,;};  the  surgeon  now 
passes  the  other  end  down  the  trachea  beyond  the  wound,  a  step  some- 
times accompanied  with  much  difficulty,  and  one  which  is  aided  by 
the  pioneering  use  of  probes  and  small  bougies  or  catheters.  The 
object  of  the  surgeon  should  be  to  place  this  lower  end  of  the  tube 
only  just  below  the  tracheal  opening,  so  that  air  is  drawn  in  from  the 
end  projecting  through  the  mouth  into  the  trachea,  without  leaving 
any  needless  length  of  the  tube  here  or  in  one  bronchus  for  fear  of 
setting  up  irritation  and  secretion.  To  prevent  the  child  pulling  out 
the  tube  the  hands  should  be  secured  for  the  first  few  hours,  and  to 
prevent  the  tube  being  bitten,  it  is  well  to  pass  a  piece  of  drainage- 
tube§  over  the  first  few  inches.  This  end  is  then  secured  with  tapes 
around  the  head.  The  tube  may  be  left  in  from  twelve  to  eighteen 
hours,  according  to  the  amount  of  secretion  and  the  facility  with  which 
the  tube  is  blocked.  While  this  treatment  is  being  carried  out  it  is 
well  to  isolate  the  child  in  a  separate  ward,  as  the  breathing  through 

*  See  a  paper  by  Mr.  Bilton  Pollard  {Lancet,  1887)  on  this  subject. 

f  It  is  more  easy  to  pass  the  tube  this  way  owing  to  the  facility  with  whicli  the  tube, 
when  passed  from  above,  finds  its  way  into  tlie  (esophagus. 

J  The  tube  will  be  found  to  pass  readily  behind  the  soft  palate. 

^  This  simple  means  is  much  better  borne  by  the  child  than  the  gag.  I  owe  its 
suggestion  to  an  old  friend,  Arthur  E.  Poolman. 


360  OPERATIONS    ON    THE    HEAD    AND    NECK. 

the  tube  is  very  noisy,  being  often  accompanied  by  very  loud  bub- 
bling sounds,  and  the  aspect  of  the  child  while  this  necessary  dilating 
of  the  larynx  is  going  on  is  one  of  apparently  great  distress.  When 
it  is  evident  the  tube  is  clogged  it  must  be  withdrawn  and  cleansed, 
and,  a  little  anassthetic  being  given,  again  inserted.  At  any  time,  if 
needed,  the  cannula  must  be  re-inserted  and  artificial  respiration  per- 
formed. It  will  readily  be  understood  that  during  this  time  the  pres- 
ence of  the  surgeon,  and  reliable  assistants  who  will  not  lose  their 
heads,  and  nurses  with  much  tact  and  temper,  are  pre-eminently 
required.  Even  when  laryngeal  breathing  is  restored  and  the  tube 
has  been  dispensed  with,  the  child  must  be  carefully  watched,  espe- 
cially at  night.  If  natural  breathing  fails,  it  is  better,  whenever  there 
is  time,  to  replace  the  Macewen's  tube  through  the  larynx  rather  than 
to  re-insert  the  tracheotomy-tube  into  the  old  wound,  a  mode  of  relief 
which  is  top  likely  to  be  resorted  to  on  account  of  its  facility,  but  one 
which  tends  to  keep  up  the  sinus-like  nature  of  the  wound  in  the 
trachea,  and  brings  back  that  most  pernicious  tendency  of  the  child  to 
prefer  and  confide  in  this  mode  of  breathing. 

Complications  of  the  After-treatment. 

(a)  Hpemorrhage. — This  is  not  common  ;  if  immediate,  it  is  due  to 
some  vessels  having  been  left  unsecured.  Later  on,  it  may  be  brought 
about  by  ulceration  of  the  trachea  by  the  cannula,*  separation  of  the 
false  membrane  by  sloughing ;  a  velvety  and  swollen  condition  of  the 
mucous  membrane;  or  by  prominent  granulations.  The  treatment  is 
clearl}'-  preventive,  to  dispense  with  a  tube,  especially  a  metal  one,  as 
soon  as  possible,  and  from  the  first  to  use  one  of  appropriate  length 
and  curve  (p.  352). 

(6)  A  Sloughy  Condition  of  the  Wound. — If  this  is  threatening,  atten- 
tion must  be  paid  to  the  tightness  of  the  tapes,  so  that  the  cannula  is 
not  needlessly  buried  in  the  wound,  and  to  the  wearing  of  a  collar  of 
lint  behind  the  shield.  The  tube  must  be  removed  at  intervals,  or  re- 
placed by  an  india-rubber  one,  air  tending  to  enter  without  a  tube  as 
soon  as  the  edges  of  the  wound  are  set  and  rigid.  If  the  wound  is  not 
only  sloughy,  but  gangrenous  and  diphtheritic,  in  addition  to  frequent 
cleaning  with  a  camel's-hair  brush,  the  use  of  antiseptic  powder  and 
lotion,  stronger  measures,  such  as  the  application  of  pure  nitric  or 
carbolic  acid,  will  be  called  for.  The  general  treatment  will  not,  of 
course,  be  neglected  in  these  cases. 

(c)  Eiwphy senna. '\ — This  is  usually  the  result  of  a  faulty  operation. 

*  Some  undoubted  cases  of  ulceration  into  the  innominate  after  low  tracheotomies 
in  children  are  on  record — e.g.,  Path.  Soc.  Trans.,  vol.  xi.  p.  20. 

t  On  this  subject  the  reader  should  consult  the  laborious,  accurate,  and  researchful 
papers  of  my  old  friend  Dr.  Champneys,  in  vols.  Ixv.  Ixvii.  and  Ixviii.  of  tlie  Afed., 
Chir.  Trans.,  and  his  work  on  Artificial  Respiration.     The  following  are  amongst  the 


TRACHEOTOMY.  361 

The  incision  into  the  trachea  is  either  wrongly  placed,  i.e.,  it  is  not  in 
the  same  line  with  that  in  the  soft  parts,  or  it  is  too  small — perhaps 
two  small  ones  have  been  made;  very  rarely  is  the  emphysema  due 
to  too  large  an  incision  in  the  trachea.  Or,  the  incision  may  have 
been  correctly  made,  but  some  fault  connected  with  the  tube  may  pro- 
duce the  emphysema ;  thus  it  may  have  been  originally  too  short,  or 
have  been  pushed  out  of  the  wound  by  swelling  of  the  soft  parts,  or 
by  coughing.  As  a  rule,  this  complication  is  not  dangerous  unless  it 
be  extreme  in  very  3^oung  children,  or  unless  it  travel  deeply ;  under 
these  circumstances  scarification   must  be  made  use  of,  if  possible. 

(d)  Ulceration  of  the  Trachea. — This  is  usually  due  to  the  pressure  of 
a  cannula  faulty  in  length  or  curve,  much  more  rarely  to  separation 
of  membrane  or  sloughs.  There  are  no  definitely  characteristic  signs 
of  this  complication  ;  the  following  point  to  it :  Streaks  of  blood  ex- 
pectorated a  day  or  two  after  the  operation,  and  perhaps  discoloration 
of  the  lower  end  of  the  tube.  This  accident  is  especially  likely  to 
occur  in  cases  of  diphtheria,  as  the  vitality  of  the  tissues  is  here  much 
lowered.  The  tube  should  be  left  out  if  possible,  or  an  india-rubber 
one  substituted,  and  worn  as  short  as  possible,  and  cut  obliquely  so 
that  the  end  does  not  impinge  upon  the  anterior  wall  of  the  trachea. 
If  it  is  necessary  to  dispense  with  all  tubes,  attempts  may  be  made  to 
keep  the  edges  of  the  tracheal  wound  stitched  to  that  in  the  soft  parts 
for  a  few  hours,  or  Mr.  Golding  Bird's  dilator  may  be  worn. 

(e)  Suppuration  in  Mediastina. — This  is  a  rare  complication.  When 
it  does  occur  it  is  liable  to  be  very  rapid.  It  results  from  a  descend- 
ing cellulitis  from  the  wound.  The  only  treatment  is  prevention  by  a 
well-performed  operation  and  by  attention  to  the  wound. 

Other  complications  which  are  not  surgical  may  of  course  be  pres- 
ent— viz..  Extension  of  exudation  downwards.  General  infection. 
Paralysis.  Albuminuria.  Broncho-pneumonia,  a  very  frequent  one, 
known  by  a  rise  of  temperature  with  frequent  respiration  and  dyspnoea, 
dulness  on  percussion,  bronchial  breathing,  with  large  bubbling  and 
crepitant  rales. 


practical  conclusions  with  which  his  pages  abound  :  (1)  Emphysema  of  the  anterior 
mediastinum,  often  associated  with  pneumothorax,  occurs  in  a  certain  number  of  trache- 
otomies. (2)  The  conditions  favoring  tliis  are,  division  of  the  deep  cervical  fascia, 
obstruction  to  the  air-passages,  and  inspiratory  efforts.  (3)  The  incision  in  the  deep 
cervical  fascia  downwards  should  not  be  longer  than  needful ;  it  should  on  no  account 
be  raised  from  the  trachea,  especially  during  inspiratory  efforts.  (4)  The  frequency  of 
emphysema  probably  depends  much  on  tlie  skill  of  the  operator,  especially  in  inserting 
the  tube.  (5)  The  dangerous  period  during  traclieotomy  is  the  interval  between  the 
division  of  the  deep  cervical  fascia  and  tiie  etHcient  introduction  of  the  tube.  (6)  If 
artificial  respiration  is  necessary,  tlie  tissues  should  be  kept  in  apposition  with  the 
trachea,  and  any  manipulations  performed  without  jerks. 


362  OPERATIONS  ON  THE  HEAD  AND  NECK. 

TUBAGE  OP  THE  LARYNX  AS   A    SUBSTITUTE  FOR 
TRACHEOTOMY  IN  MEMBRANOUS  LARYNGITIS. 

This  is  one  of  those  new  modes  of  treating  an  old  disease  about 
which  it  is  difficult  to  give  a  decided  opinion,  as  the  matter  is  still 
siib  judice. 

Attention  was  called  to  this  subject  by  Dr.  Mace  wen*  in  1880.  It 
has  been,  recentl}^,  more  prominently  brought  forward  in  America.f 

The  advantages  claimed,  if  verified,  will  no  doubt  be  very  great. 
Of  these  the  chief  are — (1)  That  objection  on  the  part  of  friends  is  less 
likely  than  in  the  case  of  tracheotomy ;  (2)  That  the  tubes  are  easily 
and  quickly  introduced;  (3)  That  there  is  no  severe  and  difficult 
operation;  (4)  That  the  inspired  air  is  warm  and  moist;  (5)  That  the 
tubes  are  self-cleansing;  (6)  That  there  is  no  prolonged  after-treat- 
ment. 

The  tubes  used  have  been  mainly  of  two  kinds — (a)  Macewen's 
long  cylindrical  tubes  of  the  pattern  of  gum-elastic  catheters,  intro- 
duced from  the  mouth  into  the  trachea  through  the  larynx,  and 
removed  at  intervals  of  about  twelve  hours  for  cleansing ;  (b)  O'Dwyer's 
short  tubes  (under  3  inches)  of  metal  with  the  antero-posterior  diam- 
eter larger  than  the  lateral.  These  ai*e  self-retaining,  partly  by  an 
enlarged  head  which  rests  upon  the  ventricular  bands,  and  partly  by 
a  fusiform  enlargement  a  little  lower  down.  They  are  introduced  and 
removed  from  the  mouth  by  special  instruments.  A  gag  must  be 
used. 

I  am  unable  to  recommend  intubation.  Within  a  few  months  of 
the  appearance  of  Dr.  Macewen's  paper  I  made  use  of  his  method  in 
three  patients  with  membranous  laryngitis  at  the  wish  of  my  friend 
Dr.  Goodhart.  Every  one  of  these  came  to  tracheotomy,  most  of  the 
drawbacks  enumerated  below  being  most  strongly  present.  I  ought 
to  say  that  of  Dr.  O'Dwyer's  tubes  I  have  no  personal  experience,  but 
I  am  most  strongly  of  opinion  that,  in  children  at  least,  they  cannot 
meet  with  a  large  amount  of  general  success.  Their  necessarily 
narrow  chink-like  calibre  appears  to  me  to  be  certain  to  obstruct  the 
free  expectoration  of  mucus,  membrane,  etc.,  which  is  so  essential  in 

*  Brit.  Med.  Journ.,  July  24  and  31,  18S0.  Dr.  Macewen's  cases  were  all  four  in 
adults,  the  two  acute  ones  l)eing  cases  of  oedema  of  the  glottis. 

t  Dr.  O'Dwyer's  first  paper  is  in  the  New  York  Med.  Journ.,  August,  1885.  Mr. 
Symonds,  in  his  summary  alluded  to  at  p.  363,  gives  the  following  references  of  papers 
by  followers  of  Dr.  O'Dwyer — viz.,  Dr.  Waxhara  {Chicago  Med  Journ.,  March,  18SR; 
Journ.  Am,er.  Med.  Assoc.,  October  24,  1885,  and  July  23,  1837)  and  Dr.  Ingals  {New 
York  Med.  Journ.,  July  2  and  9,  1887).  Dr.  Waxliam's  results  have  no  doubt  im- 
proved, but  in  the  Chicago  Med.  Journ.  and  Ejcani.,  November,  1885,  Ann.  of  Surg., 
January,  1886,  four  cases  are  given  which  were  treated  by  him,  after  O'Dwyer's  plan, 
of  which  only  one  recovered. 


TEACHEOTOMY.  363 

these  cases.  Even  when  this  is  liquid  and  abundant,  I  fear  that  the 
tubes  will  be  plugged;  when  the  expectoration  is  dry,  thick,  and 
tenacious,  its  escape  must  surely  be  impossible. 

Drawbacks :  (1)  The  tubes  are  likely  to  become  plugged  ;  (2)  There 
is  very  great  difficulty  in  getting  children  to  take  sufficient  food,  as 
swallowing  is,  in  them  certainly,  much  embarrassed.  The  importance 
of  getting  sufficient  food  down  in  these  cases  has  already  been  alluded 
to,  p.  857  ;  (3)  Part  of  what  liquids  are  taken  now  easily  finds  its  way 
into  the  trachea  and  lungs ;  (4)  The  tube  may  be  coughed  out ;  (5) 
The  facilities  for  extracting  membrane,  spraying  the  trachea,  etc.,  are 
much  fewer  than  after  tracheotomy. 

Mr.  Symonds,  in  a  summary*  of  the  results  of  O'Dwyer's  method, 
states  that  in  passing  the  tubes  membranes  may  be  pushed  down,  thus 
increasing  the  dyspnoea,  and,  with  this  difficulty  before  us,  he  points 
out  that  it  will  be  wise,  when  making  use  of  intubation,  to  be  prepared 
for  immediate  tracheotomy  ;  while  I  feel,  I  trust  sufficiently,  that  the 
results  of  tracheotomy  for  croup  admit  of  very  great  improvement,  I 
doubt  if  intubation  will  be  more  successful.  I  venture  to  think  that 
this  is  one  of  those  diseases  in  which  sufficient  attention  has  not  been 
paid  to  some  of  the  anatomical  surroundings.  I  shall,  perhaps,  be 
condemned  as  holding  a  pessimist's  views  when  I  say  that,  consid- 
ering the  narrowness  of  the  glottis,  its  proneness  to  spasm,  the  ready 
downward  extension  of  the  disease,  the  age  and  rapid  exhaustion  of 
the  patients,  I  doubt  much  if  it  is  not  expecting  too  much  when  a 
larger  proportion  of  cures  are  looked  for  here,  either  by  tracheotomy 
or,  still  less,  I  think,  by  tubage.  And  while  I  allow  that  I  have  not 
myself  had  jjersonal  experience  of  the  recent  modification  of  tubage, 
I  would  add  that  I  have  very  lately  seen  two  cases  in  which  the  im- 
proved method  was  made  use  of  with  much  temporary  eclat,  followed 
by  tracheotomy,  deferred,  but  ultimately  called  for,  and  by  fatal  results. 

OTHER  INDICATIONS  FOR  TRACHEOTOMY. 

(i.)  Syphilitic  and  Tubercular  Ulceration. — Tracheotomy  is 
more  frequently  called  for  in  the  first  of  these,  in  which  also  it  is 
decidedly  more  useful.  The  conditions  which  demand  it  temporarily, 
are  oedema  of  the  glottis  setting  in  on  old  mischief,  fibroid  thickenings, 
which  may,  later,  yield  to  treatment,  and  more  permanently,  prob- 
ably, deep  ulceration,  necrosis,  and  cicatricial  contraction. 

In  tubercular  mischief  tracheotomy  rarely  gives  much  relief,  dysp- 
noea being  now  a  rarer  misery  than  cough  and  difficulty  of  swallowing, 
both  of  which  are  conditions  which  may  be  intensified  by  the  pres- 
ence of  a  tube. 

*  Brit.  Med.  Journ.,  November  19,  1887. 


364  OPERATIONS    ON    THE    HEAD    AND    NECK. 

(ii.)  Malignant  Disease  of  the  Larynx.— Here  tracheotomy 
is  often  called  for.  Till  statistics  of  extirpation  of  the  larynx  are  more 
complete,  the  question  which  of  these  modes  of  operative  interference 
has  the  soundest  basis  must  remain  uncertain.  One  difficulty  alone 
which  besets  this  matter  is  scarcely  to  be  surmounted,  and  that  is  that 
an  increasing  number  of  cases  shows  that,  to  be  really  successful, 
extirpation  of  the  larynx  must  be  performed  early,  but  how  many 
patients  will  submit  to  it  at  this  stage  ?  (p.  370). 

In  deciding  between  advising  a  palliative  tracheotomy  and  extirpa- 
tion of  the  larynx  the  surgeon  will  be  guided  by  the  condition  of  the 
disease  and  that  of  the  patient.  The  latter  operation  can  alone  be 
justified  when  the  disease  is  strictly  localized.  Enlargement  of  the 
lymphatic  glands,  extension  of  the  disease,  especially  in  cases  of  car- 
cinoma, to  the  pharynx,  back  of  the  tongue  or  tonsil,  should  put  this 
operation  aside.  Again,  the  condition  of  the  patient,  how  far  he  is 
exhausted,  how  far  his  strength  is  sufficient  for  such  an  operation  as 
extirpation,  how  far  he  gains  ground  after  a  preliminary  tracheotomy, 
have  all  to  be  considered. 

(iii.)  Acute  Laryngitis. — The  rapidity  with  which  this  may  run 
a  fatal  course,  especially  after  exposure  to  cold  in  reduced  consti- 
tutions, is  well  known.  If  treatment,  including  application  of  strong 
solution  of  silver  nitrate  and  scarification  of  the  aryteno-epiglottidean 
folds  and  adjacent  parts  fails  to  relieve  the  dyspnoea,  tracheotomy 
should  be  performed  at  once  to  meet  the  increasing  exhaustion. 

(iv.)  Certain  Spasmodic  Affections,— e.g..  Aortic  Aneurism 
and  Tetanus. — Owing  to  these  diseases  destroying  life,  usually  in 
other  ways,  tracheotomy  is  rarely  called  for  here.  Occasionally,  how- 
ever, the  laryngeal  dyspnoea  which  they  bring  about  calls  for  this 
operation. 

Probably  there  is  no  form  of  dyspnoea  more  agonizing  to  the  patient 
or  more  distressing  to  the  friends,  than  that  which  may  accompany 
thoracic  aneurism.  The  surgeon,  however,  when  called  upon  to  per- 
form tracheotomy  in  one  of  these  terrible  cases,  must  remember  that 
the  dyspncea  may  be  tracheal  as  well  as  laryngeal  in  its  origin,  and 
that  it  is  in  the  latter  only  that  operation  will  give  relief. 

I  would  refer  my  readers  on  this  point  to  one  of  Dr.  Bristowe's  in- 
teresting Lumleian  Lectures,*  and  especially  to  this  passage :  "  De- 
struction of  the  functional  activity  of  one  recurrent  laryngeal  nerve  is 
attended  with,  of  course,  paralysis  of  the  corresponding  vocal  cord 
(which  can  be  recognized  by  means  of  the  laryngoscope),  with  impair- 

*  Lancet,  May  10,  1879.  Dr.  Bristowe  goes  on  to  show  that  the  exacerbations  of 
dyspnoea  in  narrowing  of  the  trachea  may  be  due  partly  to  spasm  of  the  muscular 
fibres,  but  mainly  to  accumulation  of  mucus  below  the  narrowing,  and  to  the  difficulty 
of  dislodging  it  by  coughing. 


TRACHEOTOMY.  365 

ment  of  the  musical  quality  of  the  voice,  and  apparently  with  some 
difficulty  of  swallowing,  owing  to  the  tendency  of  food  to  slip  into  the 
trachea,  but  is  certainly  not  necessarily  attended  with  stridor  or 
dyspnoea ;  in  the  second  place,  compression  of  the  trachea  involves 
stridor  and  dyspnoea,  which  is  often  paroxysmal  and  is  liable  to  end 
in  sudden  death,  but  does  not  itself  interfere  with  intonation  or  pho- 
nation,  excepting  in  so  far  as  it  may  render  the  voice  weak  by 
diminishing  the  supply  of  wind  to  the  vocal  organ."  As  the  paryox- 
ysmal  nature  of  the  dyspnoea  may  then  be  met  with  in  cases  of  press- 
ure on  the  air-tube  below  the  larynx  as  well  as  in  laryngeal  dyspnoea, 
the  chief  points  to  rely  on  will  be  the  result  of  a  laryngoscopic  exami- 
nation, and  the  freedom  of  the  lungs  and  air-tube  from  pressure.  Dr. 
Hall  *  thinks  that  "  the  al^sence  of  respiratory  excursions  of  the 
larynx  points  to  the  chief  impediment  being  below  the  glottis." 

With  regard  to  tracheotomy  in  tetanus,  the  same  warning  has  to  be 
given.  In  the  rarer  cases  in  which  tetanus  threatens  life  by  asphyxia 
and  not  by  exhaustion,  the  surgeon,  before  performing  tracheotomy, 
must  decide  where  lies  the  seat  of  the  asphyxia.  In  the  few  cases 
which  I  have  seen  in  which  asphyxia  closed  life  in  this  disease,  the 
asphyxia  was  due  to  spasm  of  the  muscles  of  respiration,  including 
the  muscles  of  inspiration  and  those  of  expiration — e.g.,  the  ab- 
dominal muscles  also.  The  fatal  spasm  thus,  usually,  not  lying 
in  the  larynx,  tracheotomy  seems  contraindicated,  unless  it  were 
done  with  the  object  of  relieving,  with  the  aid  of  artificial  respiration, 
that  congested,  gorged  condition  of  the  lungs  which  is  due  to  the  con- 
tinued spasm  of  the  muscles  of  respiration.  And  it  is  to  be  feared  that 
if  these  steps  were  taken,  the  gentle  violence  of  artificial  respiration 
would,  as  has  happened  with  tracheotomy  itself  in  this  disease,  only 
bring  on  a  final  and  fatal  spasm. 

(v.)  Scalds  of  the  Upper  Aperture  of  the  Larynx.— Tra- 
cheotomy is  here  usually  deferred  till  late,  and  its  want  of  success  is 
well  known.  This  is  not,  however,  an  instance  of  cause  and  effect,  the 
mortality  in  these  cases  being  rather  due  to  the  shock,  pain,  and  ina- 
bility to  take  sufficient  food.  Unless  the  case  is  seen  late,  tracheotomy 

*  Clin.  Soc.  Trans.,  vol.  xix.  p.  82.  Quoting  from  Gerhardt  {Lehrh.  d.  Ausc,  Tubin- 
gen, 1871),  Dr.  Hall  points  out  that  in  a  case  of  aortic  aneurism  tlie  following  causes 
for  dyspnoea  (Dr.  Powell,  Reynolds's  Syst.  of  Med.,  vol.  v.  p.  32)  may  all  be  pi'eseht 
together:  (1)  Undoubted  paresis  of  the  abductors  of  the  cords.  (2)  Though  tlie  post- 
mortem may  "  not  show  any  very  distinct  bulging  inwards  of  the  trachea,  the  aorta 
and  sac  being  emptied  of  blood,  yet  I  can  readily  believe  that  during  life,  when  these 
parts  were  distended  with  blood,  considerable  pressure  was  exerted  on  the  traciiea,  and 
that  this  narrowing  led  to  accumulation  of  the  tough  mucus  which  so  bothered  the 
patient"  (3)  Gairdner  {Clin.  Med.,  p.  486)  states  that  paroxysms  of  dyspnrea,  closely 
resembling  those  of  asthma,  may  be  occasioned  by  compression  of  one  of  the  pulmonary 
plexuses. 


366  OPERATIONS    ON    THE    HEAD    AND    NECK. 

should  not  be  performed  in  these  cases  till  a  trial  has  been  made  of 
scarification,  or  rather  of  acuj^uncture,  by  means  of  a  guarded  bistoury 
point,  of  the  mucous  membrane  of  the  epiglottis  and  the  glosso-epi- 
glottidean  and  aryteno-epiglottidean  folds,  the  left  fore-finger  guiding 
the  point  of  the  instrument.  In  doing  this,  the  surgeon  must  remem- 
ber the  amount  of  dyspnoea  which  is  already  present,  and  the  cer- 
tainty that  this  will  be  increased  by  the  struggles  of  the  child,  b}''  the 
finger  coming  in  contact  with  these  inflamed  jiarts,  and  at  any  moment 
the  cliild  must  be  turned  on  its  side,  artificial  respiration  performed, 
or  even  tracheotomy  resorted  to. 

(vi.)  Foreign  Bodies  in  the  Air-passages. — We  will  suppose 
a  child  brought  to  the  surgeon  with  a  history  of  having  swallowed  one 
of  the  usual  foreign  bodies.     Two  questions  now  call  for  an  answer. 

(1)  Is  there  a  foreign  body  at  all  in  any  part  of  the  air-passages?  and 

(2)  if  so,  where  is  it?  In  regard  to  the  first  question,  it  is  well  to 
remember  that  the  history  is  often  far  from  clear,  especially  in  children, 
and  the  symptoms  by  no  means  as  obvious  as  they  are  often  described 
to  be.  Thus,  the  chief  aids  in  distinguishing  the  entrance  of  a  foreign 
body  from  such  a  disease  as  membranous  laryngitis  are  the  sudden 
onset  and,  not  unfrequently,  the  well-marked  intermissions.  The 
sympton)s  characteristic  of  the  entrance  of  a  foreign  body  into  the 
larynx — viz.,  the  urgent  dyspnoea,  the  cyanosis,  the  struggling  against 
impending  death — may  not  be  got  at  on  account  of  the  youth  of  the 
patient,  or  because  no  one  saw  the  onset;  while  if  the  body  has  passed 
from  tlie  larynx  into  the  trachea,  or  into  one  bronchus,  the  dyspnoea, 
brassy  cough,  and  alteration  in  the  voice,  may  all  have  disappeared 
before  the  surgeon  sees  the  child,  and  yet  he  will  be  expected  to  give 
a  definite  opinion.  Again,  the  body  may  have  been  coughed  up,  and 
perhaps  swallowed.  Again,  in  adults,  usually  hysterical  and  egotis- 
tical women,  who  come  with  a  history  of  cancer,  dysphagia,  owing  to 
a  pin  which  they  aver  to  be  in  their  throats,  the  diagnosis  will  be  far 
from  easy.* 

Having  settled  that  a  foreign  body  is  really  present,  the  surgeon, 
unless  tracheotomy  is  urgently  called  for,  tries  to  decide  where  the 
body  is  lodged.  A  careful  examination  should  be  made  with  a  good 
light  and  with  the  finger  in  the  fauces,  and  with  the  laryngoscope  when 
feasible,  any  information  about  the  size  and  nature  of  the  body  having 
been  previously  obtained. 

(a)  A  large  or  irregular  body,  such  as  bolted — i.e.,  unmasticated — 
food,  or  artificial  teeth,  usually  lodge  above  the  upper  aperture  of  the 
larynx,  and  cause  urgent  and  often  fatal  dyspnoea.     If,  however,  the 

*  I  would  refer  my  readers  to  some  instructive  remarks  by  Mr.  Lund  on  the  delusive 
impressions  which  may  arise  from  the  imagined  swallowing  of  false  teeth,  etc.  (Hunt. 
LecL,  1885,  p.  34.) 


FOREIGN    BODIES    IN   THE    BRONCHI.  367 

first  attack  be  survived,  bodies  of  considerable  size — e.g.,  a  plate  with 
one  or  two  false  teeth,  or  halfpennies — have  been  known  to  lodge  near 
the  base  of  the  epiglottis  and  aryteno-epiglottideon  folds  for  a  very- 
considerable  time. 

Snch  cases  should  be  treated  by  laryngotomy  to  meet  the  urgent 
dyspnoea,  and  extraction  of  the  bodies  either  by  the  finger,  or  appro- 
priate forceps,  or  probangs. 

(/?)  A  small  and  light  body — e.g.,  a  bead,  a  pea,  or  more  likel}'  an 
irregular  one,  as  a  bit  of  nutshell — may  stick  in  the  rima  or  ventricle 
of  the  larynx.  If  the  first  urgent  symptoms  pass  off  without  opera- 
tion,* the  position  of  the  body  will  be  pointed  to  by  the  shortness  of 
the  intermissions  between  the  attacks  of  spasm,  and  by  the  pain  and 
the  marked  alteration  of  the  voice. 

The  treatment,  here,  would  be  first  to  perform  a  high  tracheotomy, 
and  to  dislodge  the  body  from  below  with  a  female  catheter  or  bougie 
of  appropriate  size,  the  cricoid  cartilage  being  divided  if  needful.f  If 
the  body  cannot  l)e  dislodged  in  this  way,  a  partial  or  complete  thy- 
rotomy  (p.  345)  must  be  performed. 

(j)  If  the  body  pass  through  the  larynx  it  will  depend  mainly  on  its 
outline  and  weight  whether  it  remain  in  the  trachea  or  pass  into  one 
of  the  bronchi'.  Thus,  if  it  is  light  and  smooth — e.g,,  a  cherry-stone — 
it  may  frequently  shift  its  position,  and  then,  from  time  to  time  rising 
into  the  larynx,  cause  spasm,  and  thus  attacks  of  urgent  dyspnoea, 
with  paroxysmal  cough  and  temporary  aphonia. 

In  such  cases  tracheotomy  should  be  performed  with  a  free  opening 
into  the  air-tube,  this  being  kept  open  by  wire  ligatures  passed  through 
the  edges  of  the  wound  and  tied  behind  the  neck,  or  a  dilator  such  as 
Mr.  Golding  Bird's  may  be  inserted. 

{8)  If  the  body  is  smooth  and  heavier  it  will  probably  fall  into  one 
of  the  bronchi.     This  subject  is  next  dealt  with  separately. 

FOREIGN  BODIES  IN  THE  BRONCHI. 

Amongst  these  may  be  tracheotomy  tubes,^  especially  ill-made  ones, 
tubes  worn  too  long,  particularly  if  a  low  operation  has  been  done 

*  Occasionally,  when  the  body  is  in  the  ventricle,  the  consequences  may  be  very 
slight  for  a  long  time,  especially  if  it  is  smooth  and  soon  coated  with  mucus  and  partly 
encapsnled.  Mr.  Durham  (Syst.  Surg.,  vol.  i.  p.  760)  mentions  a  case  of  Dfesault's,  in 
which  a  patient,  with  a  cherry-stone  in  one  of  the  ventricles,  refused  operation  and  lived 
for  two  years,  death  then  taking  place  from  laryngeal  disease. 

f  In  adults,  attempts  at  removal  with  the  laryngoscope  and  laryngeal  forceps,  aided 
by  a  20  per  cent,  solution  of  cocaine  may  be  successful. 

X  Dr.  Cohen  (Inter.  Encycl.  Surgery,  vol.  v.  p.  665)  thus  speaks  of  the  frequency  with 
which  these  bodies  have  slipped  in  when  ill-made  or  corroded  :  "This  source  of  the 
accident,  so  readily  avoided  by  proper  circumspection  and  admonition,  is  so  inex- 
cusable that  I  desire  to  emphasize  the  point  with  quite  an  array  of  references :  Porter, 


368  OPERATIONS   ON   THE   HEAD   AND   NECK. 

(p.  351) ;  pebbles ;  fruit  stones ;  part  of  toy-whistles ;  pieces  of  nut- 
shells ;  etc.,  etc. 

Site  of  Lodgment. — It  has  been  shown  by  Mr.  Goodall  that,  owing  to 
the  septum  being  a  little  to  the  left  and  the  right  bronchus  the  larger, 
the  foreign  body  usually  lodges  in  this.  According  to  M.  Bourdillat's 
statistics,*  out  of  156  cases  of  impaction  80  were  in  the  trachea,  35  in 
the  larynx,  26  in  the  right  bronchus,  and  15  in  the  left.  Out  of  21  cases 
analyzed  by  Prof.  Gross,t  in  which  death  took  place  without  operation, 
and  without  expulsion  of  the  foreign  body,  in  4  the  foreign  substance 
was  situated  in  the  larynx ;  in  1  partly  in  the  trachea,  partly 
in  the  larynx ;  in  3  in  the  trachea ;  in  1  in  the  right  bronchial 
tube;  in  1  in  the  lung;  in  9  in  the  right  pleural  cavity.  Out  of 
42  cases  subjected  to  operation  and  general  treatment,  the  extraneous 
substance  was  situated  twice  positively,  and  11  times  probably,  in  the 
right  bronchial  tube,  4  times  certainly,  and  4  times  probably,  in  the 
left  bronchus  tube ;  7  times  in  the  trachea  and  14  times  in  the  larynx. 
From  these  statistics  it  would  appear  that  the  trachea,  larynx,  and 
right  bronchus  are  the  most  likely  places  in  which  a  foreign  body  will 
be  arrested. 

Evidence  of  a  J^oreign  Body  having  lodged  in  a  Bronchus. — Perhaps 
there  may  be  a  histor}^  of  a  foreign  body  in  the  mouth  ;  pain  dull,  and 
heavy  behind  sternum,  at  about  its  junction  with  the  second  right 
costal  cartilage ;  J  shortness  of  breath,  cough,  expectoration  ;  more  or 
less  diminution  of  breath  sounds  over  a  portion  of  the  chest-wall  ;§ 
rales ;  increased  breath  sounds  on  the  opposite  side ;  and,  later  on,  evi- 
dence of  inflammation  and  destruction  of  lung-tissue. 

On  the  Larynx  and  Trachea,  p.  144;  Gross,  Foreign  Bodies  in  the  Air  Passages,  p.  325; 
Albert,  Arch.  f.  Clin.  Chir.,  Bd.  viii.  s.  177 ;  Waters,  Brit.  Med.  Journ.,  vol.  i.  1868,  p. 
141  ;  Boston  Med.  and  Surg.  Journ.,  February  23,  1871;  Buck,  Trans.  New  York  Acad. 
Med.,  1870;  Pick,  Trans.  Path.  Soc,  1870,  p.  416;  Ogle,  Med.  Times  and  Gaz.,  1870, 
vol.  ii.  p.  531;  Holthouse,  Lancet,  1872,  vol.  i.  p.  113;  Ogle  and  Lee,  Lancet,  1872, 
vol.  i.  p.  81 ;  Hulke,  Lancet,  1876,  vol.  ii.  p.  785  ;  Davy,  Bi'it.  Med.  Journ.,  1876,  vol.ii. 
p.  45;  Bnrow,  Berl.  Klin.  Woch.,  No.  36,  1876;  Thornton,  Tracheotomy,  p.  36;  Howse, 
iMncet,  April  17,  1877." 

*  Cohen,  loc.  supra  cit.,  p.  668. 

f  Durham,  Syst.  of  Surg.,  vol.  i.  p.  758. 

X  The  division  of  the  trachea  is  opposite  the  spine  of  the  third,  in  some  cases  the 
fourth,  dorsal  vertebra.  In  front,  this  division  is  on  the  level  of  the  junction  of  the 
first  with  the  second  bone  of  the  sternum.  The  root  of  the  spine  of  the  scapula  is  on  a 
level  with  the  third  intercostal  space.  A  stethoscope  placed  here  would  cover  the 
bronchus,  more  especially  the  right  (Holden). 

§  "Obstruction  of  the  left  bronchus  usually  produces  absence  of  respiration  over  the 
entire  lung  of  that  side,  but  occlusion  of  the  right  bronchus  usually  produces  absence 
of  respiration  over  the  lower  lobe  of  that  side  only,  the  division  of  the  bronchus  taking 
place  much  nearer  the  bifurcation,  and  the  foreign  body  rarely  lodging  above  the  point 
of  division"  (Dr.  Cohen,  loc.  supra  cit.,  p.  671). 


FOREIGN    BODIES    IN    THE    BRONCHI.  369 

Treatment. — A  low  tracheotomy  (p.  351)  should  be  performed  at 
once,  and  with  as  free  an  opening  as  possible.  The  edges  of  the 
incised  trachea  being  held  open  with  sutures  of  wire  (not  too  fine), 
inversion  and  succussion  should  be  tried,  and  the  mucous  membrane 
excited  with  a  feather  or  probe  in  order  to  excite  cough. 

If  provided  with  suitable  instruments  (see  below),  the  surgeon  may 
at  once  proceed  to  attempts  at  extraction,  but  it  is  well  to  remember 
the  fact  pointed  out  by  Mr.  Durham,*  that  in  a  large  proportion  of 
the  cases  which  have  done  well,  expulsion  has  not  been  effected  until 
some  time  after  the  operation.!  Whenever  a  fit  of  coughing  brings 
the  body  into  view,  the  next  inspiration  will  draw  it  back  again,  so 
that  careful  watching  and  prompt  use  of  forceps,  etc.,  will  be  required. 

If  from  its  shape,  or  from  the  interval  which  has  elapsed,  the  body 
is  too  firmly  impacted  to  be  expelled  by  exciting  coughing,  the  fol- 
lowing instruments  should  be  resorted  to,viz. :  Gross's  flexible  German- 
silver  tracheal  forceps,  long  and  slender  and  easily  bent  into  any 
curve  ;  or  Durham's  forceps,  equally  flexible  and  giving  a  better  grip. 

Failing  the  above,  stout  silver  or  copper  wire  should  be  bent  into 
the  form  of  a  blunt  hook,  or  a  long  probe  fashioned  into  the  same 
shape.J  The  above  instruments  are  first  used  as  sounds  and  searchers, 
aided  by  the  forefinger,  which  can  be  passed  as  far  as  the  bifurcation 
of  the  trachea,  and  the  orifice  of  each  primary  bronchus,  as  pointed 
out  by  Dr.  Sands. § 

The  operation  should  not  be  too  prolonged,  especially  if  the  parts 
are  inflamed :  when  this  condition  has  subsided  spontaneous  expul- 
sion will  often  take  place.  Annandale||  recommended  that  this  be 
promoted  by  the  patient's  taking  a  deep  inspiration  ;  the  surgeon  then 
closes  the  tracheotomy  wound  till  expiration,  thus  rendered  more 
violent,  follows  and  often  drives  out  the  body. 

*  Loc.  supra  cit.,  pp.  769-770. 

t  Thus,  in  a  case  of  Dr.  Smith's  at  Halifax  {Lancet,  1876,  vol.  ii.  p.  148)  a  boy,  aged 
eight,  swallowed  a  whistle  (as  thick  as  a  penholder,  and  about  J  inch  long)  on  January 
8 ;  it  was  not  expelled  till  May  7,  the  child  having,  for  the  previous  six  weeks,  had 
increasing  cough  and  expectoration  with  increasing  emaciation.  The  child  recovered, 
and  Dr.  Smith  draws  attention  to  the  fact  that,  owing  to  the  very  slight  discomfort,  it 
is  doubtful  if  the  cause  would  have  been  recognized  if  the  impacted  body  had  not  pro- 
duced a  whistling  sound,  and  tlius  demonstrated  its  presence. 

J  Mr.  Hulke  {Lancet,  1876,  vol.  ii.  p.  785)  used  a  long  piece  of  German-silver  wire, 
one  end  of  which  was  bent  into  a  blunt  hook  about  ^  inch  long,  and  the  wire  again 
bent  about  IJ  inch  above  this,  at  an  angle  roughly  estimated  as  that  which  the  right 
bronchus  and  trachea  include.  The  other  end  was  bent  into  a  large  loop,  the  plane  of 
which  coincided  with  that  of  the  tracheal  end  of  the  wire  beyond  the  angle,  and  thus 
allowed  it  to  be  guided  into  the  right  bronchus. 

^  Amer.  Clin.  Led.,  vol.  ii.  p.  199,  Putnam,  New  York,  1876.  Quoted  by  Mr.  Dur- 
ham, loc.  supra  cit.,  p.  771. 

II  Med.  Times  and  Oaz.,  February  27,  1875. 

24 


370  OPERATIONS   ON   THE    HEAD   AND   NECK. 

EXCISION  OF  THE  LARYNX,  PARTIAL  AND  COMPLETE 

(Figs.  81-83). 

The  value  of  these  operations  is  still  sub  judice;  much,  therefore,  of 
the  following  will  require  confirmation  : 

Indications. 

(1)  Sarcoma  and  carcinoma  of  the  larynx,  if  intra-laryngeal.  Some 
recommend  its  performance  in  the  above  affections  if  they  are  extra- 
laryngeal  as  long  as  they  are  circumscribed  and  not  widely  infiltrating 
adjacent  structures  and  glands.*  Owing  to  the  persistency  with  which 
recurrence  will  take  place  in  these  cases  it  is  probable  that  extirpation 
of  the  larynx  will  give  no  better  results  as  to  the  amount  of  real  relief 
which  it  affords  than  a  palliative  tracheotomy,  which,  according  to 
some  observers  {e.g.,  Lennox  Browne,  vide  wfra),  gives  a  prolongation 
of  life  amounting  to  two  and  a  half  years.  It  must  never  be  forgotten 
that  this  operation,  apart  from  the  question  of  relapse,  has  certain 
special  risks  of  its  own — e.g.,  shock,  septic  cellulitis,  etc.,  broncho- 
pneumonia— and  that  thus  an  early  extirpation  may,  if  fatal,  shorten 
a  life  materially.  Furthermore,  the  surgeon,  if  once  he  begin  an  extir- 
pation in  these  cases  of  extra-laryngeal  growth,  may  not  know  when 
to  stop,  owing  to  the  extent  of  the  disease.f 

Dr.  Newman,  in  two  very  interesting  lectures  on  Tumors  of  the 
Larynx,!  speaks  thus  of  the  indications  for  the  operation  in  malignant 
disease:  "  Laryngeal  carcinomata  are,  as  a  rule,  intrinsic  for  a  con- 
siderable period,  and  therefore  the  time  during  which  the  operation 
may  be  performed  is  considerable,  but,  notwithstanding,  it  is  of  the 
utmost  importance  that,  if  the  operation  is  to  be  performed  at  all,  it 
should  be  undertaken  as  soon  as  the  disease  is  recognized.§     When 

*  In  some  cases  this  can  only  be  told  during  the  operation,  as  in  a  case  of  Mr. 
Holmes's  {Brit.  Med.  Journ.,  1884,  vol.  ii.  p.  809),  in  which  at  the  time  of  the  operation 
part  of  the  epithelioma  was  found  to  lie  outside  the  larynx,  extending  upwards. 

t  Thus  Czerny  (quoted  by  Dr.  Newman,  loc.  infra  cit.)  in  a  case  of  lympho-sarcoma, 
which  had  perforated  the  thyroid  cartilage  and  involved  the  neighboring  glands, 
operated  repeatedly.  The  internal  and  external  carotids,  the  internal  jugular,  and  the 
vagus  were  divided,  and  the  patient  died  fifteen  months  after  the  primary  operation. 

X  Brit.  Med.  Journ.,  1886,  vol   i.  p.  868. 

I  On  this  subject  the  difficulty  of  always  recognizing  carcinoma — a  matter  to  which 
a  well  known  case  has  lately  drawn  much  attention — Dr.  Semon  made  some  weighty 
remarks  at  the  International  Medical  Congress  in  1!^81  {Trans.,  vol.  iii.p.  264).  "Who, 
in  a  large  proportion  of  these  cases,  will  take  upon  hilnself  to  diagnosticate  early  and 
positively  carcinoma  ?  and  who,  again,  if  carcinoma  is  diagnosticated,  will  say  posi- 
tively whether  it  is  in  an  early  or  more  advanced  stage?"  The  speaker  went  on  to 
point  out  that  not  only  is  the  laryngoscopic  differential  diagnosis  often  exceedingly 
difficult  for  a  long  time,  but  that  in  a  large  proportion  of  cases  the  administration  of 
potassium  iodide  produces  an  improvement,  and,  in  some,  apparently  even  a  temporary 
arrest  of  the  disease.     With  regard  to  the  second  question — "  Is  it  always  possible  to 


EXCISIOX    OF    THE    LARYNX.  371 

the  disease  is  associated  with  infiltration  of  lymphatic  glands,  or  if  the 
primary  tumor  be  extrinsic,*  or  if  there  be  persistent  bronchitis  or 
pulmonary  catarrh,  an  operation  is  contraindicated  ;  for  if  it  be  per- 
formed in  such  cases,  not  only  may  the  patient  be  deprived  of  the 
small  remnant  of  life  left  to  him,  but  the  chances  of  eradicating  the 
disease  are  very  remote.  Cases  are  on  record  in  which,  besides  the 
larynx,  portions  of  the  thyroid  gland,  trachea,  oesophagus,  and  phar- 
ynx have  been  extirpated,  but  the  results  are  far  from  encouraging, 
not  only  on  account  of  the  immediate  dangers  of  the  operation,  but 
also  from  the  fact  that  recurrence  takes  place  in  a  limited  time." 

In  deciding  as  to  whether  the  disease  is  extra-laryngeal  the  surgeon 
will  be  aided  by  observing  whether  the  larynx  moves  in  deglutition,f 
and  from  side  to  side,  whether  the  glands  are  enlarged,  and  by  infor- 
mation gained  by  the  finger  passed  from  the  mouth,  and  of  course  by 
the  rate  of  the  changes  observed  with  the  laryngoscope. 

That  malignant  disease  of  the  larynx  can  be  occasionally  removed 
with  great  benefit  to  the  patient,  even  when  the  glands  outside  are 
clearly  involved,  is  shown  b}''  Dr.  Gerster's  case,  quoted  at  p.  381. 

Mr.  H.  Morris;}:  showed,  from  a  case  which  he  brought  before  the 
Clinical  Society,  that  removal  of  the  larynx  might  be  called  for  in 
cases  where  a  palliative  tracheotomy  had  been  done ;  but  owang  to 
the  downward  extension  of  the  growth,  the  tracheotomy-tube  becom- 
ing a  source  of  continual  irritation  'and  distress,  though  absolutely 
necessary  for  respiration,  the  suppurative  cough  and  dyspnoea  could 
not  be  relieved  b}^  other  means.  The  patient,  a  man  of  fifty-nine, 
sank  on  the  eighth  day  from  exhaustion.  The  whole  of  the  growths 
had  been  removed,  and  there  were  no  secondary  deposits. 

A  valuable  contribution  has  been  lately  made  to  the  statistics  of 


decide  wliether  the  carcinoma  is  in  an  early  or  advanced  stage — i.e.,  has  or  has  not  an 
infection  of  the  neighboring  parts  already  taken  place?"  Dr.  Semon  quoted  an 
instructive  case  of  a  patient,  aged  sixty,  who,  having  had  syphilis  twenty  years  before, 
began  to  suffer  from  his  throat  in  October,  1880.  The  diagnosis  remained  long  doubt- 
ful between  specific  perichondritis  and  carcinoma,  potassium  iodide  not  yielding 
decisive  results.  It  was  not  till  early  in  March,  1881,  that  the  diagnosis  of  carcinoma 
could  be  actually  established,  and  at  this  time  the  cervical  lymphatics  became  slightly 
hardened,  but  not  perceptibly  enlarged.  On  March  9  tracheotomy  was  required,  and 
exactly  one  u-eek  after  the  operation  a  swelling  of  the  size  of  a  hazel-nut,  quickly  increas- 
ing, appeared  behind  the  right  sterno-mastoid.  Dr.  Semon  points  out  that  if  extirpation 
had  been  performed  instead  of  tracheotomy  there  would  have  been  a  recurrence  within 
one  week  of  the  operation. 

*  E.f).,  commencing  in  the  pharynx  and  involving  the  larynx  secondarily  by  invad- 
ing the  e{)iglottis  or  aryteno-epiglottldean  folds. 

t  It  is  noteworthy  that  the  larynx  may  be  movable  and  yet  the  pharynx  be  impli- 
cated, as  in  a  case  reported  by  Surgeon-Major  McLeod  (Lancet,  April  26,  1884). 

X  Brit.  Med.  Journ.,  1886,  vol.  ii.  p.  975. 


372  OPERATIONS    ON    THE    HEAD    AND    NECK. 

this  subject  by  Mr.  Butlin  *  from  whose  book  the  following  quotations 
are  taken  : 

^'■Mortality  Due  to  the  Operation. — In  respect  to  this  question,  the 
most  valuable  information  may  be  obtained  from  the  very  complete 
tables  of  Hahn.  In  these  there  are  seventy-four  cases  of  excision  of 
the  entire  larynx  for  new  growths,  but  three  of  the  seventy-four  must 
be  excluded  from  consideration,  because  the  disease  for  which  the 
larynx  was  removed  was  neither  sarcomatous  nor  carcinomatous 
(tuberculosis,  papillomata,  and  jiolypi).  Of  the  seventy-one  patients, 
twenty-five  died  within  the  first  fortnight,  and  five  within  six  or  seven 
weeks  of  the  operation.  Death  was  due,  in  the  very  large  majority, 
to  pneumonia  or  purulent  bronchitis,  and  was  not  in  any  case  due  to 
recurrence  of  the  disease.  There  ajDpears,  therefore,  to  be  a  mortality 
of  about  40  per  cent.,  directly  due  to  the  operation  itself.  But  this  is 
only  a  partial  statement  of  the  actual  facts.  To  obtain  a  more  accu- 
rate knowledge,  it  is  necessary  to  consider  separately  the  cases  of 
sarcoma  and  of  carcinoma,  for  not  one  of  the  patients  whose  larynx 
was  removed  on  account  of  sarcoma  died.  This  may  be,  of  course,  a 
mere  accident,  and  a  much  larger  number  of  cases  may  give  a  very 
difi"erent  result 

"  There  remain,  then,  sixty-five  cases  in  which  the  larynx  was  en- 
tirely removed  on  account  of  carcinoma,  and,  of  these,  thirty  were 
fatal  from  the  immediate,  or  almost  immediate,  results  of  the  operation 
— a  very  enormous  mortality,  which  can  only  be  justified  by  a  bril- 
liant success  on  the  side  of  complete  cure 

"A  study  of  the  nine  cases  in  Hahn's  tables,  in  which  only  a  par- 
tial excision  was  performed,  may  perhaps  throw  some  light  on  the 
enormous  mortality  due  to  the  major  operation.  In  every  one  of 
them,  one-half  of  the  larynx  was  removed — in  seven  for  carcinoma,  in 
two  for  sarcoma — and  only  one  patient  died  from  the  direct  effects  of 
the  operation,  a  person  who  had  made  admirable  progress  until  the 
twelfth  day,  when  sudden  and  unexpected  death  took  place,  appar- 
ently from  some  unknown  cause.  Here,  again,  the  number  of  cases 
is  too  small  to  admit  of  a  comparison  between  them  and  the  cases  of 
removal  of  the  entire  larynx  for  carcinoma,  but  the  difference  is  so 
striking  that  one  cannot  but  draw  from  it  the  conclusion  that  the 
severity  of  the  operation  must  have  much  to  do  with  the  greater  mor- 
tality. To  this,  however,  must  be  added  the  better  position  of  the 
parts  after  partial  excision,  and  the  greater  ease  with  which  the 
patients  can  be  fed,  and,  no  doubt,  the  less  extensive  nature  of  the 
disease  before  operation. 

"  Cures  Due  to  Operation. — It  will  be  convenient,  first,  to  consider 
the  sarcomas,  on  account  of  their  small  number  and  the  ease  with 

*  Oper.  Surg,  of  Maliy.  Dis.,  p.  192. 


EXCISION    OF   THE   LARYNX.  373 

.which  an  analysis  may  be  made  of  them.  We  have  records  of  six 
complete  and  two  partial  excisions  for  sarcomatous  tmnors.  The 
further  history  of  five  of  the  six  is  known.  Two  died  with  recur- 
rence of  the  disease — one  at  the  end  of  seven,  and  the  other  at  the 
end  of  fifteen,  months.  Of  the  remaining  three,  one  was  quite  well 
and  free  from  disease  six  years  after  the  operation,  the  second,  two 
years  after  the  excision,  and  the  third  died  of  phthisis  a  year  and  a 
half  after  the  removal  of  the  larynx,  without  any  sign  of  recurrence  of 
the  disease.  In  these  cases  the  operations  had  been  very  extensive,  and 
had  included  the  removal  of  parts  outside  the  larynx  as  well  as  of  the 
larynx  itself.  In  the  two  instances  in  which  the  excision  was  partial, 
and  concerned  half  the  larynx,  the  result  of  one  was  that  the  patient  died 
ten  months  after  the  operation  of  inflammation  of  the  lungs  or  pleura, 
without  any  appearance  of  recurrence,  although  the  operation  in- 
cluded the  removal  of  the  side  of  the  pharynx  and  base  of  the  tongue. 
In  the  other  case  there  was  no  recurrence  some  time  after  the  opera- 
tion, but  the  length  of  time  is  not  stated. 

"  Far  otherwise  are  the  results  when  we  come  to  consider  the  exci- 
sion of  the  larynx  for  carcinoma.  It  has  been  already  shown  that 
thirty  of  the  sixty-five  patients  for  whom  complete  excision  was  per- 
formed died  of  the  operation.  Of  the  remaining  thirty-five,  twenty 
are  known  to  have  suffered  from  recurrence  and  to  have  died  within 
a  few  months  of  the  operation.  The  duration  of  life  varied  from  three 
to  nine  months,  thirteen  of  the  twenty  dying  within  the  first  six 
months.  There  remain,  therefore,  fifteen  patients  to  account  for.  In 
one  case  the  further  result  was  unknown ;  two  patients  died  of  pneu- 
monia at  the  end  of  three  and  four  months  respectively,  apparently 
in  both  instances  without  recurrence.  In  five  of  the  remaining  twelve 
cases,  less  than  a  year  had  elapsed  between  the  operation  and  the  last 
report.  There  are,  then,  seven  patients'  alive  without  recurrence  at 
periods  respectively  of  fourteen,  sixteen,  sixteen,  seventeen,  eighteen, 
nineteen  months,  and  four  years.  Even  the  most  ardent  admirer  of 
active  interference  in  cases  of  malignant  disease  can  scarcely  regard 
these  results  as  satisfactory,  for  only  one  patient  can  be  claimed  as 
cured  by  the  operation.  The  table  of  seven  partial  excisions,  although 
it  contains  only  one  death  which  could  in  any  way  be  attributed  di- 
rectly to  operation,  is  not  very  attractive.  Three  of  the  six  jjatients 
died  of  recurrence  of  the  disease — one  at  the  end  of  three,  one  at  six, 
and  one  at  seventeen  months.  There  was  no  recurrence  in  the  re- 
maining three  cases,  but  only  fourteen  months  had  elapsed  in  one, 
eleven  months  in  the  second,  and  an  unknown  time  in  the  third. 

"  It  is  only  fair,  in  the  consideration  of  these  results  of  excision  of 
the  larynx  for  carcinoma,  to  say  that  there  does  not  appear  to  have 
been  any  great  care  in  the  selection  of  fit  cases  for  operation.     The 


374  OPERATIONS    ON    THE    HEAD    AND    NECK. 

establishment  of  the  diagnosis  of  laryngeal  cancer  seems,  in  a  large 
number  of  instances,  to  have  sufficed,  and  the  patient  was  forthwith 
submitted  to  operation.  Further,  some,  if  not  many,  of  the  patients 
were  greatly  weakened  by  the  effects  of  the  disease,  and  were  not  fit 
to  undergo  even  a  gentle  surgical  operation,  much  less  an  operation 
requiring  really  a  strong  constitution.  Better  results  may  in  future 
certainly  be  obtained  by  performing  the  operation  with  the  help  of 
Hahn's  tube,  performing  a  preliminary  tracheotomy  some  days  before 
the  excision  in  those  cases  in  which  the  patient  is  exhausted  by  long- 
continued  dyspnoea,  and  feeding  through  a  tube  and  funnel  during 
the  first  days  (or  longer  if  need  be)  after  the  operation. 

"  And  better  results  may,  I  am  sure,  be  obtained,  so  far  as  the  cure 
of  the  patient  is  concerned,  by  selecting  cases  of  intrinsic  carcinoma, 
and  rejecting  all  cases,  whether  of  intrinsic  or  extrinsic  carcinoma,  in 
which  there  is  associated  affection  of  the  lymphatic  glands." 

(2)  A  few  cases  may  arise  in  which  there  is  no  malignant  disease, 
but  the  laryngeal  cavity  is  destroyed,  and  a  constant  source  of  discom- 
fort and  danger.  Thus,  in  Dr.  Henry  Watson's  case,*  a  gentleman 
aged  thirty-six,  palliative  tracheotomy  had  been  performed  to  relieve 
the  ulceration  of  tertiary  syphilis.  The  larynx  healed,  but  the  puck- 
ering gave  rise  to  a  condition  of  matters  by  which  some  portion  of  all 
fluid  nutriment  and  saliva  made  its  way  into  the  trachea  and  occa- 
sioned fits  of  spasmodic  cough.  Feeding  by  the  tube  did  not  prevent 
the  saliva  from  passing  down,  and,  in  almost  every  instance,  on  its 
withdrawal  some  fluid  regurgitated  and  some  part  of  it  passed  into  the 
trachea,  etc.  The  patient  rallied  from  the  operation  for  removal  of 
the  larynx,  but  died  some  weeks  afterwards  from  pneumonia. 

Both  in  this  case  and  one  in  which  Rubio,  of  Madrid,!  removed  the 
larynx  for  necrosis  of  the  cartilages  in  a  man  aged  fortv-one,  with  a 
fatal  result  on  the  fifth  day,  there  was  great  debility  before  the  opera- 
tion. With  regard  to  this  group  of  cases,  Dr.  Foulis  remarked,  "  May 
we  excise  the  larynx  as  we  would  a  knee-joint  when  it  is  hopelessly 
thickened  and  ulcerated  ?  When  the  breathing  and  voice  are  im- 
peded, and  the  parts  are  no  longer  capable  of  distension  by  dilatation, 
it  appears  to  me  that  the  diseased  larynx  may  be  properly  removed 
and  replaced  by  an  artificial  one." 

As  to  the  propriety  of  removing  part  of  the  larynx  in  these  cases  of 
stenosis  and  ulceration.  Dr.  Foulis  did  not  favor  it,  as  two  cases  in 
which  he  had  performed  a  modified  operation  of  this  kind  did  not  do 
well,  one  dying  of  diabetes,  and  the  other  developing  perichondritis 
and  dying  in  three  months.     The  operation  does  not,  however,  seem 

■  *  Quoted  by  Dr.  Foulis,  Trans.  Iniemat.  Med.  Corujr.,  1881,  vol.  iii.  p.  251. 
f  Foulis,  loc.  supra  cit.,  p.  252. 


EXCISION   OF    THE    LARYNX.  375 

to  have  been,  in  either  case,  what  is  now  considered  partial  removal 
of  the  larynx. 

(3)  It  is  possible  that  excision  of  the  larynx  may,  in  the  future,  be 
performed  as  part  of  an  operation  for  removal  of  a  thyroid  gland  the 
site  of  malignant  disease.  It  is  w^ell-known  how  fatal  removal  of  the 
thyroid  glai^d  often  is  in  these  cases  from  interference  with  the  recur- 
rent laryngeal,  injury  to  which  is  often  unavoidable.  It  has  been 
suggested  *  that,  in  these  cases,  if  it  will  facilitate  extirpation  of  the 
malignant  disease,  or  if  there  is  reason  to  think  that  the  above  nerve 
has  been  injured,  the  larynx  be  removed,  thus  not  only  giving  more 
room  for  dealing  with  the  original  disease,  but  also  for  removing  a 
fertile  source  of  dyspnoea  and  spasm. 

Operation. 

PreUmlaary  Tracheotomy. — This  should  be  done  a  week  at  least  before 
the  operation  for  excision.  The  advantages  are  that:  (1)  The  patient 
gets  used  to  breathing  through  an  artificial  apparatus.  (2)  The  easier 
breathing  Avill  improve  his  general  health.  (3)  The  lungs,  being  less 
engorged  after  thus  .receiving  air  freely,  will  be  less  likely  to  become 
the  seat  of  broncho-pneumonia.  (4)  When  the  operation  is  performed 
less  time  will  be  taken  up,  j^nd  no  blood  will  enter  from  this  source. 
(5)  The  trachea  will  have  become  adherent  to  the  skin,  and  thus  tends 
less  to  fall  away  when  the  larynx  is  severed  from  it,  so  preventing 
diffusion  of  pus. 

With  regard  to  the  site  of  the  tracheotomy,  it  should  be  low  rather 
than  high,  for  if  done  high  up  (1)  it  may  be  too  near  the  seat  of  the 
disease,  and  (2)  a  more  important  point,  if  a  high  operation  is  per- 
formed, the  lower  end  of  the  excision-wound  will  come  into  parts 
infiltrated  and  altered,  and  thus  difl^icult  to  distinguish  at  a  very  criti- 
cal stage  of  the  operation.f 


*  Dr.  Fonlis  [loc.  supra  cit.,  p.  258)  quotes  briefly  a  case  of  Dr.  Bircher's,  in  which 
a  scirrhous  thyroid  had  been  excised  ;  six  months  later  recurrence  took  place,  and  the 
larynx  was  excised  with  part  of  the  gullet.  Death  took  place  in  ten  days  from  pneu- 
monia and  gangrene  of  the  lung.  Prof.  Caselli  (Inter.  Med.  Congr.,  1881,  vol.  iii.  p. 
262)  stated  that  he  had  performed  partial  excision  of  the  larynx  in  the  case  of  an  enor- 
mous myxo-fibro-chondroma  of  the  hyoid  and  larynx,  the  patient,  who  was  much 
exhausted,  dying  in  three  days. 

t  On  this  account  Gussenbauer  prefers  a  high  tracheotomy  with  horizontal  severance 
of  the  trachea  as  the  initial  step  in  laryngectomy,  owing  to  the  fact  that  after  a  pre- 
liminary tracheotomy  the  tissues  become  so  infiltrated  and  matted  that  they  are  less 
readily  recognized,  and  also  complicate  the  detachment  of  the  soft  parts  and  make 
haemorrhage  more  serious.  On  this  point  Mr.  Butlin's  argument,  that  in  patients 
exhausted  by  long-continued  dyspnoea  there  can  be  no  question  that  it  is  essential  to 
success  that  tracheotomy  should  be  performed  some  time  previous  to  the  operation, 
will  carry  great  weight  with  most  surgeons. 


376  OPERATIONS    ON    THE    HEAD    AND    NECK. 

While  the  above  is  believed  to  be  the  Aviser  course,  some  have  had 
good  results  with  a  high  operation,  i)erformed  before  or  at  the  same 
time  as  the  removal  of  the  larynx.  Thus  Mr.  Lennox  Browne  (loc. 
infra  ciL),  having  performed  a  high  tracheotomy  (between  the  second 
and  third  rings),  introduced  Hahn's  tampon-cannula,  consisting  of  a 
tube  surrounded  with  compressed  sponge.*  Other  operators  have 
dispensed  with  tracheotomy  altogether. 

The  patient  being  brought  under  the  influence  of  an  anaesthetic 
given  at  first  in  the  ordinary  way,  and,  later  on,  if  desired,  through 
the  tampon,  the  surgeon  must  decide  whether  he  will  perform  the 
operation  with  the  patient  in  the  usual  position,  cutting  from  above 
downwards,  or  with  the  head  supported  in  the  position  dependent, 
pillows  being  placed  under  the  dorsal  spine,  the  incision  being  now 
made  fnmi  below  upwards. f 

The  former  course,  if  the  tampon  to  be  used  is  a  reliable  one,  is 
probably  the  best,  the  tampon-cannula  of  Trendelenberg,  Dr.  Semon's 
modification  of  this  (Fig.  80),  or  Dr.  Hahn's  tampon  being  introduced 
instead  of  the  ordinary  tracheotomy  cannula.  If  no  tracheotomy  is 
performed  either  some  time  previously  or  immediately  before  the 
operation,  the  median  incision  being  made,  the  trachea  is  usually  first 
isolated  and  divided,  and  then  a  large  tube  or  tamj^on-cannula  in- 
serted. 

*  Cannnlae  with  air  or  water  tampons  are  liable  to  the  serious  drawback  of  sudden 
rupture.  On  this  account  it  seeuis  best  to  nse  ordinary  cannulse  surrounded  with 
aseptic  sponge.  Mr.  Butlin  prefers  the  tube  recommended  by  Hahn  for  these  reasons : 
(1)  It  consists  of  an  inner  and  an  outer  tube,  tiie  inner  of  which  is  the  longer,  pro- 
jecting about  li  inches  in  front  of  the  shield  so  as  to  render  the  entrance  of  blood  very 
unlikely.  In  order  to  prevent  tliis  projection  inconveniencing  the  operator,  it  is  made 
to  bend  down  parallel  with  the  trachea  before  it  stands  out  at  a  right  angle  with  the 
neck.  (2)  The  outer  tube  is  partly  covered  with  a  layer  of  compressed  sponge,  pre- 
viously soaked  in  iodoform  and  ether  (1  in  7).  Tlie  sponge  is  fastened  on  by  sutures 
and  by  silk  tied  round  its  upper  and  lower  end.  (S)  About  ten  minutes  after  the 
introduction  of  the  tube  the  sponge  swells  up  from  the  absorption  of  moisture,  and  the 
entrance  of  liquids  into  the  trachea  is  thus  prevented.  This  arrangement  of  sponge 
seems  to  hold  the  tube  more  steadily  in  position  than  the  India  rubber  bag  of  Trende- 
lenberg's  tampon,  which  is  liable  to  become  slippery,  and  whicii,  moreover,  may  burst 
during  the  oneration. 

f  Dr.  Cohen  {loc.  infra  cit.)  thus  states  the  chief  merits  of  the  two  methods  :  "Ke- 
moval  from  above  downwards  is  the  moi-e  tedious.  To  some  operators  it  appears  to  be 
the  safer  plan,  inasmuch  as  it  effectively  avoids  all  risk  of  escape  of  blood  and  other 
matters  into  the  tracheal  extremity  of  a  severed  windpipe  during  the  important  stages 
of  the  dissection,  for  the  severance  of  the  larynx  from  the  trachea  is  the  last  step  of 
the  procedure  instead  of  the  first,  and  may  be  delayed  until  all  haemorrhage  is  under 
control.  The  opposite  plan  is  said  to  possess  the  advantage  that,  the  trachea  being 
taken  care  of  in  the  first  instance,  the  operator  can  proceed  more  rapidly,  and  be  re- 
lieved from  all  anxiety  as  to  the  entrance  of  blood  into  the  air-passages." 


EXCISION    OF   THE    LARYNX.  377 

If  the  operation  is  begun  from  above,  an  incision  is  first  made  from 
the  lower  border  of  the  hyoid  bone  exactly  in  the  middle  line,  verti- 
cally doAvn  to  the  level  of  the  first  or  second  ring  of  the  trachea,  and 
a  second  at  right   angles  to  the 

first,  either  at  the  level  of  the  by-  ^^^-  ^^• 

oid  bone  or  across  the  thyroid 
cartilage,  in  either  case  passing 
outwards  to  the  sterno-mastoids. 
The  vertical  incision  should  go 
down  to  the  thyroid  and  cricoid 
cartilages  and  trachea.  The  soft 
parts  over  the  thyroid  and  cri- 
coid are  then  raised  en  masse  by 
inserting  a  blunt  dissector  or  rasp- 
atory   so    close    to    the    cartilages      ^'-  ^^^^"'^  modification  of  Trendelenberg-s 

.  " .  tampou-caiinula.*    (Mackeuzie.) 

that  the   perichondrium  itself  is 

lifted  up  witli  its  relation  to  the  soft  parts  over  it  undisturbed.  This 
separation  is  carried  back  as  far  as  the  middle  of  the  junction  of 
larynx  and  pharynx,  the  thyroid  and  cricoid  cartilages  carefully 
severed  in  the  middle  line  with  stout  scissors  or  cutting  forceps,  the 
two  halves  separated  with  retractors,  and  the  interior  examined  to  see 
if  partial  removal  of  the  larynx  will  be  sufficient. 

The  above  method  of  working  very  close  to  the  cartilages  with  a 
blunt  instrument  only  was  first  used  by  Mr.  Browne  at  the  suggestion 
of  Mr.  Henry  Morris  ;  it  has  the  conspicuous  advantages  of  disturb- 
ing but  little  the  soft  parts  and  of  causing  but  trifling  haemorrhage.t 

*  This  instrument  is  thus  described  by  Sir  M.  Mackenzie  {Dis.  of  the  Throat  and 
Nose,  vol.  i.  p.  516,  Fig.  107,  from  which  the  above  illustration  is  taken) :  "  It  consists 
of  an  ordinary  tracheotomy-tube,  with  a  broad  groove  running  round  its  lower  extremity 
externally.  This  groove  receives  a  hollow  india-rubber  air-belt,  which,  when  unin- 
flated,  is  flush  with  the  surface  of  the  cannula.  A  tine  capillary  silver  tube,  soldered 
inside  the  cannula,  communicates  at  one  end  with  the  air-belt,  and,  at  the  other,  opens 
near  the  anterior  oritice  of  the  cannula.  To  this  extremity  is  attached  a  piece  of  elastic 
tubing  about  6  inches  in  length,  with  a  stopcock  at  its  free  end.  The  cannula  having 
been  introduced  into  the  trachea,  the  belt  is  inflated  by  means  of  the  tube,  and  the 
stopcock  turned  off.  The  expansion  of  the  belt  blocks  up  the  space  between  the  can- 
nula and  the  ^alls  of  the  trachea,  and  thus  renders  it  impossible  for  any  blood  to  pass 
from  the  larynx  into  the  air-passages.  It  is  very  important  not  to  fill  the  air-belt  too 
full,  as  much  pressure  suddenly  applied  to  the  trachea  is  apt  to  produce  an  asthmatic 
paroxysm."  Another  risk,  that  of  bursting  the  belt,  is  alluded  to  elsewhere.  In  Tren- 
delenberg's  original  instrument  the  capillary  tube  was  priced  outside  the  cannula,  and 
rendered  the  latter  very  difficult  of  introduction. 

f  In  thus  raising  the  soft  parts,  by  keeping  close  to  the  cartilages  of  the  larynx,  care 
should  be  taken  not  to  separate  needlessly  the  soft  parts  from  the  trachea.  Some  of  these 
— e.g.,  the  lateral  masses  of  the  thyroid  gland,  which  are  now  also  detached  with  a 
blunt  dissector — are  useful  in  preventing  descent  of  the  trachea. 


378  OPERATIONS   ON    THE    HEAD    AND    NECK. 

The  transverse  incision  was  not  found  necessary  in  this,  a  unilateral 
removal  of  the  larynx. 

Where  the  parts  do  not  admit  of  the  above  step,  or  where  the  parts 
outside — e.g.^  glands,  are  found  involved,  flaps  of  skin  and  fascia  are 
reflected,  and  the  larynx  exposed  as  freely  as  possible,  any  enlarged 
glands  now  seen  should  be  removed  and  the  crico-thyroid  arteries 
secured.  The  sterno-hj^oids  and  sterno-thyroids  are  next  ])eeled  off  from 
the  thyroid  cartilage  with  a  blunt  dissector,  or  ligatured  with  chromic 
gut  and  cut  through,  and  the  lateral  lobes  of  the  thyroid  gland  carefully 
separated  in  the  same  way,  ligatures  being  tied  at  their  junction  with 
the  isthmus,  if  needful.  The  soft  parts  at  the  sides  which  contain  the 
large  vessels,  etc.,  are  now  carefully  retracted,  and  the  larynx  being 
drawn  first  to  one  side  and  then  to  the  other,  the  constrictors  are 
divided  very  close  to  their  attachments  to  the  cricoid  and  thyroid  car- 
tilages. The  superior  laryngeal  vessels  are  next  secured  and  divided 
as  they  enter  the  thyro-hyoid  membrane.* 

Up  to  this  point  very  little  blood,  if  any,  has  entered  the  air  pas- 
sage, and  if  the  growth  have  not  caused  obstruction  the  inflation  of 
the  tampon  may  be  left  to  this  stage.  If  the  surgeon  be  unprovided 
with  one  of  these,  or  if  the  one  in  use  do  not  work  satisfactorily,  the 
larynx  had  best  next  be  detached  from  the  trachea,  the  cricoid,  or  a 
small  circle  of  this,  being  left,  if  possible,  to  give  support  later  on  for 
the  artificial  larynx.f  If,  however,  there  is  any  doubt  as  to  the  extent 
of  the  growth  downwards,  the  division  had  better  be  made  between 
the  rings  of  the  trachea  itself.  The  lower  end  of  the  trachea  is  next  to 
be  carefully  stitched  to  the  skin,  and  a  large  tube  of  vulcanite,  lead? 
etc.,  is  put  in  to  jirevent  blood,  etc.,  descending. 

The  removal  of  the  larynx  is  next  carried  on  from  below  upwards, 
especial  care  being  taken,  in  the  separation  of  the  oesophagus  from  its 
connections  to  the  trachea  and  larynx,  not  to  button-hole  it  (Foulis), 
especially  at  its  attachment  to  the  cricoid.  During  this  stage  the 
larynx  is  kept  dragged  forwards  with  vulsellum-forceps  or  a  sharp 
hook. 

If,  as  the  dissection  is  carried  upwards,  the  laryngo-pharyngeal 
junction  is  found  to  be  infiltrated,  the  anterior  and  lateral  walls  of  the 
pharynx  must  be  removed  as  well.  If  the  surgeon  decide  noAV  to  re- 
move the  epiglottis,!  the  knife  must  be  carried  upwards  through  the 

*  Mr.  Bntlin,  quoting  from  Hahn,  advises  thaty  in  detaching  the  soft  parts  of  the 
back  of  the  larynx,  bhint-pointed  scissors  should  be  used  with  a  series  of  short  snips. 

t  Hahn,  however,  removes  the  cricoid  cartilage  in  complete  extirpation  of  the  larynx, 
as  he  thinks  that,  if  left,  it  interferes  with  deglutition. 

X  "  The  weight  of  testimony  seems  to  indicate  the  propriety  of  sacrificing  the  epi- 
glottis in  all  cases  of  carcinoma,  and  in  all  others  in  which  an  artificial  larynx  is  to  be 
used  "  (Cohen). 


EXCISION    OF   THE    LARYNX. 


379 


thyro-hyoid  ligament,  so  as  to  pass  between  the  tongue  and  epiglottis, 
its  course  being  controlled  by  the  left  forefinger  passed  into  the  mouth. 
If  the  epiglottis  is  left- the  knife  is  carried  through  the  thyro-hyoid 
membrane  and  the  thyro-epiglottic  ligaments  as  well. 

As  soon  as  the  larynx  is  removed,  attention  should  be  paid  to  any 
bleeding  points,  and  the  cut  trachea  and  edges  of  the  pharynx  (if  this 
has  been  partly  removed)  stitched  most  carefully  with  carbolized  silk 
sutures  to  the  edges  of  the  skin  wound,  if  this  has  not  been  already 
done  in  the  case  of  the  trachea  ;  secure  union  being  of  the  utmost  im- 
portance to  prevent  burrowing  in  the  cellular  tissue  of  the  neck. 


PARTIAL  REMOVAL  OF  THE  LARYNX  (Figs.  81,  82,  83). 

The  unilateral  extirpation  of  the  larynx  maj?-  be  made  use  of  when, 
after  exposing  it,  partially  freeing  it  from  surrounding  soft  parts,  and 
slitting  it  open,  it  is  found  that  the  disease  is  limited  to  one  side. 

Dr.  Newman  {he. supra  cit.')  gives  the  following  as  indications:  (1) 
Malignant  disease  of  limited  extent;  (2)   Stenosis  or  obliteration  of 


Fig.  81. 


Fig.  82. 


\..cart.ofv;ris 

tSl/P.CO«NU       - 

MOT  REKiov?'    '.  t.CAPrrf 

;  SANTORINt 


nfTER-ARYTENOID. 
FOLD 


/aACMt  L.A«w-Epi<;Lorri6 

Fold. 


Epithelioma  of  the  left  cord.  From 
a  patient  in  whom  Mr.  Lennox 
Browne  successfully  removed  half  the 
larynx. 


LVENTftlClE 


ANTtRIORPORTif 
OF  CRICOta 


Inner  aspect  of  the  portion  removed. 

Iar3mx  which  cannot  be  cured  by  other  means ;  (3)  Recurrent  papillo- 
mata  not  removable  by  less  heroic  interference. 

Mr.  Butlin  (Oper.  Surg.  Mai.  Dis.,  p.  191)  is  in  favor  of  still  further 
limiting  the  operation.     "  When  the  disease  is  of  very  small  extent, 

*  I  am  indebted  to  Mr.  Lennox  Browne  for  permission  to  make  use  of  this  and  the 
next  two  ilhistrations.  They  will  be  found  in  liis  paper  (Brit.  Med.  Journ.,  February 
5,  1887),  and  in  the  second  edition  of  his  book  on  the  Throat  and  its  Diseases,  p.  457. 


I 


380  OPERATIONS    ON    THE    HEAD    AND    NECK. 

limited  to  the  true  and  false  cords  of  one  side,  not  extending  into  the 
structures  above  and  below,  not  even  adherent  to  the  cartilage,  I 
believe  the  better  course  to  pursue  will  be  to  remove  the  diseased 
structures  and  a  wide  area  of  the  surrounding  soft  tissues,  just  in  the 
same  manner  as  one  treats  an  epithelioma  of  the  lip,  without  insisting 
on  the  removal  of  even  one-half  of  the  thyroid  cartilage.  Cartilage, 
whether  calcified  or  not,  is  peculiarly  resistant  to  the  progress  of  can- 
cer, and  when  the  disease  appears  to  be  adherent  to  it,  it  is  the  peri- 
chondrium which  is  affected,  and  only  in  the  rarest  instances  the 
cartilage  itself.  Cancer  of  the  larynx  far  more  often  causes  the  death 
of  the  cartilage  piece  by  piece,  than  infiltrates  it."  While  the  above 
remarks,  coming  as  they  do  from  one  wlio  is  distinguished  for  his 
knowledge  of  malignant  disease,  and  for  being  one  of  the  few  English 
surgeons  who  have  successfully  extirpated  half  the  larynx,  are  entitled 
to  every  respect,  it  has  yet  to  be  seen  how  far  this  very  limited  pro- 
ceeding is  justifiable  in  malignant  disease,  and  how  far  Mr.  Butlin's 
comparison  above  given  is  a  just  one. 

The  advantages  of  partial  removal  at  present  seem  undoubted.  (1) 
The  mortality  33  per  cent,  after  total  extirpation  is  only  20  per  cent, 
after  unilateral ;  *  (2)  The  dangers  of  recurrence  are  not  greater  if 
cases  are  projDerly  selected ;t  (3)  The  voice  may. be  almost  perfectly 
retained  without  use  of  the  tracheal  cannula  ;  (4)  Deglutition  is  com- 
pletely preserved. 

Mr.  Lennox  Browne  (loc.  supra  cit.),  in  his  case  of  removal  of  half 
of  the  larynx  (Figs.  81,  82,  83),  having  exposed  it  by  sub-perichon- 
drial  raising  of  the  soft  parts,  divided  the  thyroid  cartilage  with  cut- 
ting forceps,  removed  the  half  by  :  (a)  Thorough  separation  of  the 
attachments  to  the  pharynx  with  the  raspatory  aided  by  the  knife- 
handle  and  finger-nail ;  (b)  Division  of  the  thyro-hyoid  membrane  as 
close  as  possible  to  its  thyroid  attachment;  (c)  Division  of  the  left 
superior  horn  of  the  thyroid  cartilage  at  its  root  by  cutting  pliers  ;  (d) 

*  Mr.  Lennox  Browne  [loc.  infra  cit.)  states  that  some  thirteen  or  fourteen  cases  have 
now  been  recorded,  and  that  in  only  one  instance  has  there  been  an  immediately  fatal 
result.     See  also  the  quotation  from  Mr.  Butlin,  p.  407. 

f  Drs.  Hahn  and  Schede  [Oerm.  Surg.  Congr.,  April,  1884;  Lond.  Med.  Record,  1884, 
p.  358)  showed  that  (1)  this  operation  was  much  less  severe ;  (2)  relapse  was  not  more 
frequent;  (3)  impairment  of  function  was  much  less.  In  one  of  Schede's  cases  the 
patient  was  a  dentist;  he  could,  after  a  while,  dispense  with  any  cannula  and  follow 
his  calling,  his  speech  not  attracting  notice.  As  a  result  of  cicatricial  contraction  a 
prominent  fold  of  mucous  membrane  had  formed,  immovable,  but  capable  of  perform- 
ing many  of  the  functions  of  the  right  cord,  the  left  moving  up  to  it,  and  thus  forming 
a  rima  glottidis.  In  the  case  of  a  well-known  barrister,  operated  on  by  Dr.  Hahn,  and 
brought  by  Dr.  Semon  before  the  Clinical  Society  (Brit.  Med.  Journ.,  1886,  vol.  ii.  p. 
975),  the  patient  recovered  so  well  that  he  was  able  to  fill  the  position  of  police  magis- 
trate. 


EXCISION   OF    THE    LARYNX.  381 

Division  in  the  middle  line  of  the  cricoid  cartilage,  in  front  and  be- 
hind ;  (e)  The  divided  half  of  the  larynx  was  then  separated  from  the 
first  ring  of  the  trachea,  and  a  few  nicks  only  were  necessary  to  re- 
move it  entire.  The  very  slight  oozing*  which  ensued  after  the 
removal  of  the  diseased  part  was  checked  by  a  slight  application  of 
the  galvano-cautery  which  would  also  destroy  any  possible  fragments 
of  diseased  tissues  not  removed.  The  left  aryteno-epiglottic  fold  was 
divided  close  to  the  cartilage  of  Wrisberg,  and  the  thyro-hyoid  mem- 
brane close  to  its  thyroid  attachment,  with  the  view  of  impairing  as 
little  as  i^ossible  the  action  of  the  epiglottis.  The  success  of  this  plan 
was  completely  shown  by  the  ease  with  which  deglutition  was  effected 
three  days  later. 

Dr.  Gerster,  of  New  York  (Ann.  of  Surg.,  Jan.,  1886),  reports  a  suc- 
cessful case  of  unilateral  extirpation  of  the  larynx,  for  alveolar  sar- 
coma, in  a  patient  aged  fifty-seven.  The  laryngoscope  showed  a  smooth 
pale  tumor  of  the  size  and  shape  of  an  almond,  commencing  in  the 
left  glosso-epiglottidean  fold,  extending  through  the  substance  of  the 
left  vocal  cord  into  the  ary-epiglottidean  fold,  and  ending  in  the  ar3^te- 
noid  cartilage  with  a  knob-like  protuberance. 

A  preliminary  low  tracheotomy  was  performed,  and  at  the  same  time 
a  deep-seated,  hard,  glandular  swelling  of  the  size  of  a  hen's-egg  was 
removed  from  the  left  sub-maxillary  region,  together  with  part  of  the 
internal  jugular  and  the  sterno-mastoid. 

About  six  weeks  later  the  left  half  of  the  larynx  was  thus  removed. 
A  tampon-cannula  was  inserted  and  distended  in  the  tracheotomy 
wound,  after  this  an  incision — commencing  at  the  upper  notch  of  the 
thyroid,  and  extending  to  the  lower  margin  of  the  cricoid  cartilage — 
laid  bare  the  larynx  in  the  middle  line.  To  this  was  added  another 
cut,  commencing  in  the  upper  angle  of  the  first,  and  extending  hori- 
zontally to  the  anterior  margin  of  the  left  sterno-mastoid.  The  crico- 
thyroid ligament  was  s^Dlit  to  admit  a  strong  pair  of  bone-pliers  for  the 
division  of  the  thyroid  cartilage,  but  it  was  found  impossible  to  per- 
form this  act,  as  the  strongly  inclined  position  of  the  cartilage  did  not 
permit  an  effective  handling  of  the  instrument.  Therefore  access  was 
gained  by  an  incision  through  the  thyro-hyoid  ligament,  and  an  exact 
division  of  the  calcified  cartilage  thus  effected.  After  this  the  epiglottis 
was  cut  through  lengthwise,  the  left  half  of  the  cri co-thyroid  ligament 
divided,  and  the  superior  thyroid  artery  included  in  a  double  ligature 
and  cut  through.  The  most  difficult  part  of  the  operation  consisted 
in  the  dissection  of  the  lateral  portions  of  larynx  and  pharynx,  closely 
adherent  to  the  carotid  artery  by  cicatricial  tissue,  caused  by  the  pre- 


*  Only  two  small  vessels  required  torsion,  a  happy  result,  due  to  the  use  of  the  ras- 
patory, and  to  keeping  so  close  to  the  cartilage. 


382 


OPEEATIONS    ON   THE    HEAD    AND    NECK. 


vious  extirpation  of  the  glands.  Shallow  incisions,  running  parallel 
with  the  course  of  the  artery,  were  cautiously  made,  and  the  difficult 
task  seemed  almost  completed,  when  suddenly  a  powerful  jet  of  arte- 
rial blood  welled  up  from  the  bottom  of  the  wound.  The  bleeding 
point  was  easily  secured,  and  then  it  was  ascertained  that  the  trunk 
of  the  superior  thyroid  (doubly  ligatured  further  below  prior  to  this) 
had  been  cut  away  level  with  its  origin  from  the  carotid.  Two  catgut 
ligatures  were  apj^lied  around  the  main  trunk  above  and  below  the 
forceps,  and  when  the  instrument  was  removed  a  round  hole  in  the 

Fig.  84. 


Fig.  8.S. 


Laryngoscopic  view  from  the  same 
patient  four  months  after  operation. 


Dr.  Foulis's  modification  of  Giissen- 
bauer's  artificial  larynx.  The  upper 
tube  is  shown  above,  b,  The  lower 
tube,    c,  The  reed.    (Mackenzie.) 

side  of  the  carotid  became  visible.  The  remaining  adhesions,  corre- 
sponding to  the  left  lateral  portion  of  the  pharynx  could  now  be  easily 
dissected  out.  The  patient  made  a  good  recovery,  but  a  plastic  oper- 
ation was  required  to  close  the  wound,  and  about  seven  weeks  after 
the  operation  a  small  suspicious  glandular  swelling  was  removed  from 
the  supra  clavicular  region.  Five  months  later  the  general  condition 
was  remarkably  improved.  Swallowing  of  solids  and  semisolids  was 
excellent,  drinking  had  to  be  slowly  and  carefully  done.  The  patient 
could  speak  with  a  hoarse  whisper,  readily  understood  at  a  distance 


EXCISION    OF   THE    LARYNX.  383 

of  10  or  15  feet.  The  cicatrices  were  soft  and  normal.  The  laryngo- 
scope showed  a  smooth,  rather  extensive,  scar  occupying  the  left  side 
of  the  pharynx  and  larynx.     The  right  cord  was  normal. 

After- Treatment.  —  All  haemorrhage  being  arrested,  the  wound  is 
brushed  over  with  a  10  per  cent,  zinc-chloride  solution,  or  iodoform 
and  ether,  and  dusted  with  iodoform ;  one  or  two  sutures  may  be  placed 
at  the  ends  of  the  transverse  incision,  but  the  vertical  incision  should 
be  left  widely  open  for  drainage,  the  wound  being  lightly  packed  with 
strips  of  iodoform  or  sal  alembroth  gauze.  These  should  not  be 
changed  too  frequently,  and,  at  each  renewal  of  the  dressings,  the 
wound  should  be  irrigated  with  some  antiseptic  solution  and  carefully 
cleansed  with  camel's-hair  brushes.  Thiersch,  to  prevent  lung  infec- 
tion, keeps  the  head  low  for  the  first  few  days.  Mr.  Butlin  advises 
that  an  ordinary  tracheotomy  tube  covered  with  iodoform  gauze  be 
substituted  for  the  compressed  sponge-tube  at  the  end  of  twenty-four 
hours.  The  gauze  should  be  sufficiently  thick  to  stop  any  discharges 
getting  into  the  trachea,  and  should  be  changed  once  a  day.  It  is  very 
important  to  keep  the  wound  sweet  and  clean  to  prevent  the  pneu- 
monia which  has  so  frequently  j^roved  fatal  after  excision.  Nourish- 
ment must  be  supplied,  for  the  first  week,  by  a  soft  tube  passed  either 
by  the  nose  or  mouth,  and  if  it  is  desirable  to  retain  this,  it  would  be 
well  to  make  trial  of  this  method  before  the  operation.  Feeding  by 
enemata  alone  is  not  reliable,  considering  the  debilitated  condition  of 
these  patients,  and  the  profound  shock  which  often  accompanies  this 
most  serious  operation. 

The  temperature  of  the  room  must  be  from  65°  to  70°.  A  moist 
carbolized  sponge  or  layer  of  gauze  should  be  kept  in  front  of  the  tra- 
cheotomy tube.  When  the  wound  has  become  firm,  the  patient  should 
be  encouraged  to  take  some  solid  food  by  the  mouth,  liquid  food  thus 
taken  having,  always,  a  greater  tendency  to  get  into  the  trachea. 

After  partial  removal,  the  patient  will  be  able  to  dispense  with  the 
cannula,  and  to  take  food  by  the  mouth  within  a  few  days  of  the  opera- 
tion. In  about  a  month,  an  artificial  larynx  may  be  fitted.  Of  these 
the  chief  forms  are  Gussenbauer's,  and  Irvine's  modification  of  this. 

The  following  account  is  taken  from  a  very  complete,  clear  and  prac- 
tical article  by  Dr.  Cohen,*  of  Philadelphia,  to  which  I  am  already 
much  indebted  for  information.  The  appliance  consists  of  three  parts  f 
— (1)  a  tracheal  cannula;  (2)  a  pharyngeal  cannula,  the  two  having 

*  Iniernat.  Encylc.  Surg.,  vol.  v.  p.  777. 

f  Originally  a  substitute  for  the  epiglottis  was  provided,  maintained  erect  by  a 
watch-spring  weak  enough  to  yield  readily  to  the  descent  of  the  base  of  the  tongue  in 
deglutition.  This  has  been  found  unnecessary  and  rather  in  the  way.  Dr.  Cohen  {loc. 
supra  cit.)  figures  an  instance  of  the  very  complicated  apparatus  which  will  be  required 
when  the  anterior  wall  of  the  oesophagus  has  been  removed. 


384  OPERATIONS    ON    THE    HEAD    AND    NECK. 

apertures  by  which  they  can  be  passed  through  each  other  and  admit 
a  free  current  of  air  from  below  upwards;  (3)  An  adjustable  plate 
carrying  a  vibratory  reed.  This  is  detachable  for  purpose  of  cleans- 
ing from  mucus,  being  pushed  in  and  out  like  a  table-drawer.  The 
apparatus  being  in  position,  the  expiratory  current,  on  its  way  to  the 
mouth,  sets  the  reed  in  vibration,  and  the  tone  thus  produced,  broken 
with  articulate  speech,  is  monotonous,  modulation  being  imprac- 
ticable. 

Great  difference  is  presented  in  the  toleration  of  these  appliances. 
In  some  instances  they  give  little  trouble,  and  are  used  with  great 
comfort.  Some  subjects  bear  the  naked  apparatus  well,  but  cannot 
tolerate  the  phenol  reed,  which  may  impede  respiration,  may  become 
obstructed  with  desiccated  mucus,  and  may  yield  a  tone  to  every 
breath  of  expiration.  Some  abandon  them  altogether,  and  stick  to  the 
simple  tracheal  cannula.  In  some  instances  saliva,  mucus,  and  food 
will  get  into  the  tubes  and  descend  into  the  trachea.  Some  patients 
prevent  the  escape  of  food  by  plugging  the  upper  orifice  when  they  eat. 

Dangers  and  Causes  of  Death. 

1.  Shock. 

2.  Exhaustion.  Both  these  are  rarely  met  with,  save  when  the 
hgemorrhage  has  been  severe. 

3.  Lung  trouble — viz.,  broncho-pneumonia,  purulent  bronchitis,  etc. 
This  is  the  most  frequent  cause  of  death,  from  the  passage  of  food, 
blood,  etc.,  down  the  trachea  in  spite  of  careful  plugging.*  Dr.  Cohen  f 
thinks  that  the  period  of  danger  from  lung  complications  does  not  last 
over  two  weeks,  and  that  if  the  patient  survive  this  date,  he  is  tolerably 
secure  up  to  the  fourth  month,  when  death  from  recurrence  begins  to 
be  imminent. 

4.  Septic  cellulitis,  mediastinitis,  etc. 

After-Condition  of  the  Patient. — This  is  a  most  important 
matter,  and  one  which  should  be  fully  explained  to  the  patient.  The 
amount  of  comfort  will  mainly  depend  upon  two  things  :  (1)  whether 
half  or  the  whole  of  the  larynx  has  been  removed  ;  (2)  whether  much 
of  the  skin  and  soft  parts  have  had  to  be  taken  away,  or  have 
sloughed. 

With  regard  to  the  first  point,  if  only  half  of  the  larynx  have  been 
removed,  the  patient  usually  swallows  early  and  easily,  and  speaks 
quietly  and  hoarsely,  but  with  very  fair  distinctness,  and  without  any 

*  If  the  patient  have,  previous  to  the  operation,  any  bronchitis,  these  fatal  lung 
complications  are  especially  likely,  the  bronchitis  running  on  into  broncho-pneumonia. 
For  this  reason  Billroth  [Clin.  Surg.,  p.  134)  urges  in  such  patients  that  every  attempt 
should  be  made  to  improve  the  bronchitis,  a  preliminary  tracheotomy  being  performed 
if  needful. 

f  Loc.  swpra  cit.,  p.  770. 


OPEEATIONS   ON    THE   THYROID    GLAND.  385 

need  of  mechanical  aid.  Where  the  whole  larynx  has  been  taken 
away,  some  such  appliance  as  that  of  Gussenbauer's  will  be  required 
to  enable  the  patient  to  make  himself  understood.  Even  after  com- 
plete removal,  if  the  pharynx  has  been  left  untouched,  the  power  of 
swallowing  will  be  but  little  impaired.  If,  however,  the  surrounding 
soft  parts  have  had  to  be  widely  extirpated,  so  large  a  gap  will  be  left 
that  swallowing  Avill  be  impossible,  and  it  will  be  necessary  to  feed  the 
patient  with  a  tube. 

While,  for  the  present,  it  must  remain  uncertain  how  far  the  after- 
condition  of  the  patient  will  be  better  than  that  foretold  after  the  earlier 
laryngectomies,*  there  is  no  doubt  that,  when  the  soft  parts  in  front 
of  the  phar3aix  have  had  to  be  extensively  removed,  the  after-condi- 
tion is  one  of  great  discomfort.f 


CHAPTER  XIIL 

OPERATIONS  ON  THE  THYROID  GLAND. 

REMOVAL  OF  THE  THYROID  GLAND,  t  PARTIAL 
AND  COMPLETE. 
Indications. 

1.  Failure  of  previous  treatment  and  increase  of  bronchocele  lead- 
ing to 

2.  Dyspnoea  sufficiently  constant  to  prevent  the  patient  from  fol- 
lowing an}^  active  employment,  or  one  of  a  sedentar^^  kind  which  in- 
volves stooping  of  the  neck  and  head. 

3.  The  existence  of  tracheal  stridor,  especially  if  accompanied  by 
much  enlargement  of  the  isthmus  (see  p.  400)  or  extension  of  the 
bronchocele  downwards. 

4.  Attacks  of  sudden,  suffocating  dyspnoea. 

It  is  not  j^et  sufficiently  recognized  by  the  profession  that  a  bron- 
chocele, whether  moderate  in  size  or  large,  ma}^  from  some  sudden  en- 

*  Thus,  Sir  M.  Mackenzie  at  the  International  Medical  Congress,  1881  {Trans.,  p. 
263),  stated  that  "the  condition  of  a  patient  after  extirpation  of  the  larynx  is  usually 
one  of  great  misery."  Dr.  Cohen,  of  Pliiladelphia,  holding  the  same  view,  drew 
attention  to  the  importance  of  distinguishing  between  ''recovery"  and  mere  "sur- 
vival after  the  operation." 

f  A  good  illustration  of  this  condition  and  an  idea  of  its  results  is  given  by  Dr. 
Cohen  from  Lange,  Fig.  1095  {Inter.  Encycl.  of  Surg.,  vol.  v.  p.  776).  He  also  points 
out  that  too  early  attempts  to  use  an  artificial  larynx  only  cause  haemorrhage,  while  an 
apparatus  which  is  adjustable  at  first,  is  often  rendered  useless  by  further  cicatrization. 

X  A  distinction  must  always  be  made  in  these  operations  between  removal  of  parts 
of  the  thyroid  itself  and  that  of  encapsulated  adenomata  in  it,  however  large. 

25 


386  OPERATIONS    ON    THE    HEAD    AND    NECK. 

gorgement  or  rupture  cause  urgent  and  fatal  dyspnoea.  A  first  attack 
may  here  only  herald  in  the  end.* 

The  following  may  be  quoted  to  prove  that  the  above  danger  is  well 
founded : 

Dr.  Hurry  (Lancet,  March  19,  1887)  gives  the  case  of  a  girl,  aged 
thirteen,  the  subject  of  a  moderate  goitre.  Dyspnoea  was  first  com- 
plained of  November  3 ;  on  November  7  dyspnoea  was  urgent,  and 
tracheotomy  was  called  for.  The  ojieration  gave  very  little  relief,  and 
death  followed  H  hour  later.  The  postmortem  examination  showed 
a  moderately  large  goitre,  the  two  lobes  of  which  entirely  encircled 
the  trachea  and  reduced  the  lumen  to  a  narrow  slit,  to  which  the 
tracheotomy  wound  did  not  quite  reach.  Dr.  Hurry  gives  the  follow- 
ing ingenious  explanation  of  the  insidiousness  and  urgency  of  the 
dyspnoea  in  these  cases  :  Owing  to  the  slowly  progressive  enlargement 
of  the  thyroid  the  dyspnoea  at  first  is  slight,  one  day  some  extra 
exertion  calls  into  play  the  additional  muscles  of  respiration — e.g., 
sterno-mastoid,  sterno-thyroid,  sterno-hyoid,  these,  pressing  on  the 
trachea,  still  further  close  its  lumen,  already  narrowed  by  the  slowly 
progressive  growth,  this  brings  about  additional  dyspnoea,  and  so  in- 
duces still  further  contraction  of  the  inspiratory  muscles,  and,  so,  to 
further  closure  of  the  trachea  and  increasing  dyspnoea  and  death. 

Dr.  Dewes  (Brit.  Med.  Juimi.,  1S79,  January  18,  p.  84)  records  the 
case  of  a  patient  who  was  found  by  the  Coventry  police  apparently 
dying  of  suffocation.  On  his  admission  into  the  hospital  a  large 
bronchocele  was  found,  and  a  free  median  incision  was  made  by  Mr. 
Read  down  to  the  tumor.  The  breathing  at  once  improved,  and  soon 
became  natural,  the  tumor  decreased  in  size,  and  all  went  well  till  the 
evening  of  the  seventh  day,  when  the  dyspnoea  suddenly  returned, 
the  tumor  again  enlarging,  the  patient  dying  in  two  or  three  minutes. 
It  was  found,  post-mortem,  that  in  the  last  agony  the  posterior  part  of 
the  tumor  had  broken  down,  giving  rise  to  a  large  extravasation  of 
venous  blood,  pressing  on  the  respiratory  nerves.  "  The  only  part  of 
the  trachea  at  all  approachable  was  under  the  manubrium  sterni, 
where  it  was  covered  by  the  innominate  artery." 

I  wish  to  draw  attention  to  this  fact,  that  extravasation  may  take 
place  suddenly  into  a  bronchocele,  thus  producing  urgent  dyspnoea. 
In  1885  a  woman,  aged  forty-four,  came  under  my  care  with  enlarge- 

*  Thus,  in  one  case,  a  woman  with  a  bronchocele  which,  as  far  as  was  known,  had  not 
given  previous  trouble,  waking  out  of  sleep  suddenly,  was  terrified  by  seeing  her  little 
child  playing  about  the  room  with  a  piece  of  wood  taken  alight  from  the  fire.  Most 
urgent  dyspnoea  set  in,  and  before  surgical  relief  could  be  given,  death  took  place  from 
suffocation.  In  another  case,  that  of  a  woman,  the  subject  of  bronchocele,  and  strain- 
ing violently  in  the  throes  of  parturition,  the  same  dyspnoea  set  in  as  rapidly,  and 
with  the  same  result. 


OPERATIONS   OX    THE    THYROID    GLAND.  387  - 

ment  of  the  thyroid,  the  right  half  having  been  increasing  in  size  for 
some  years,  but  her  chief  trouble  was  clue  to  a  swelling,  in  the  posi- 
tion of  the  isthmus,  of  the  size  of  a  small  orange.  This  had  existed 
about  a  year,  but  had  suddenly  increased  in  size,  while  the  patient 
was  singing,  six  months  before.  The  patient's  voice,  originally  an 
alto,  was  now  hoarse  and  gruff,  and  of  very  small  compass.  On  re- 
moval this  proved  to  be  an  encapsuled  adenoma  of  the  thyroid  (per- 
haps, originally,  in  the  main  cystic),  containing  in  the  centre  firm 
coagulum,  and  occupying  the  isthmus.  Two  years  later,  when  the 
patient  was  last  seen,  the  right  lobe  had  subsided  to  the  size  of  its 
fellow,  but  the  voice  was  still  deep  and  somewhat  hoarse. 

5.  Difficulty  of  deglutition,  if  associated  with  the  others  not  given. 

6.  Steady  or  rapid  enlargement,  with  or  without  dyspnoea,  if  the 
enlargement  be  in  a  downward  direction  so  as  to  become  sub-sternal. 
The  lower  down  the  growth  has  been  allowed  to  extend  the  greater 
the  risk  of  mediastinal  cellulitis,  if  an  operation  is  performed  for  the 
removal  of  the  bronchocele,  and  the  smaller  the  hope  of  giving  relief 
by  tracheotomy,  if  the  dyspnoea  comes  on  in  these  cases  too  urgently 
to  admit  of  any  attempt  at  extirpation. 

The  following  case,  given  by  Mr.  Bryant,*  is  a  good  instance  of  the 
truth  of  the  above :  A  young  man,  aged  nineteen,  three  months  before 
his  death,  "became  the  subject  of  paroxysmal  attacks  of  asthmrtic 
dyspnoea,  associated  at  times  with  a  wheezing  or  whistling  respiration 
and  some  general  enlargement  of  the  base  of  the  neck.  Three  days 
before  his  death  this  difficulty  became  extreme,  the  paroxysms  be- 
came more  frec[uent  and  more  severe,  and  on  the  day  of  his  death  a 
severe  paroxysm  took  place,  which  passed  on  to  a  forced  and  heaving 
respiration,  beyond  anything  I  had  ever  before  witnessed,  and  speedy 
death  resulted.  I  performed  tracheotomy  with  the  slender  hope  that 
some  light  might  be  thrown  upon  the  nature  of  the  case  to  guide  u& 
in  its  treament,  if  not  to  give  relief,  but  in  doing  so  what  was  jjroba- 
ble  before  became  evident — viz.,  that  the  obstruction  was  below.  I 
had  no  perforating  instrument  with  me  long  enough  to  force  down,  so 
a  female  catheter  was  used,  but  it  struck  against  some  solid  body  that 
prevented  its  progress.  After  death  the  thyroid  body  was  found  tO' 
be  much  enlarged,  but  mainly  below  the  sternum  and  along  the  sides- 
of  the  trachea.  The  trachea  below  my  opening  was  flattened  later- 
ally to  within  2  inch  of  the  bifurcation  ;  it  was  also  twisted  to  the  left,- 
and  was  surrounded  by  the  greatly  enlarged  and  firm  lateral  lobes  of 
the  thyroid." 

7.  Improvement  of  personal  appearance.  An  operation  should 
never  be  here  entertained  by  the  surgeon,  unless  he  is  dealing  with  a 

*  Surgery,  second  edition,  vol.  i.  p.  192. 


388  OPERATIONS    ON    THE    HEAD    AND    NECK. 

small  growth  and  has  sufficient  reason  to  have  confidence  in  himself 
and  his  patient  to  be  able  to  keep  the  wound  aseptic  from  first  to  last.* 
Cases  in  which  an  operation  is  contraindicated,  or  in  which  it  must  be 
performed  with  additional  caution. 

1.  Huge  bronchoceles,  especially  if  broadly  fixed. 

2.  Calcified  bronchoceles. 

3.  Those  with  ill-defined  limits. 

4.  Those  which  are  already  sub-sternal,  owing  to  the  risk  of  medi- 
astinal cellulitis. 

5.  Age — e.g.,  in  patients  over  fifty. 

6.  Patients  with  very  feeble  pulse.  Schwartz  thinks  that  feeble 
action  of  the  heart  will  be  often  met  with  in  goitre,  and  attributes  this 
partly  to  interference  with  respiration  due  to  pressure  on  the  veins 
and  the  trachea,  and  partly  to  the  intervention  of  a  more  or  less  volu- 
minous vascular  network  in  the  circulation,  thus  producing  a  strain 
on  the  heart. 

Dangers  of  the  Operation.    Immediate  and  Later. 

1.  Haemorrhage.  This  can  usually  be  met  by  paying  careful  atten- 
tion to  the  details  given  below  in  the  account  of  the  operation.  The 
arteries  are  usually  easily  commanded  ;  it  is  the  veins  which  give 
trouble,  being  numerous  and  thin-walled,  and,  in  the  severer  cases, 
met  with  at  every  step  of  the  operation.  In  these  cases  also,  when 
the  growth  is  soft  as  well  as  vascular,  any  opening  of  the  capsule  is 
liable  to  give  rise  to  flooding  of  the  wound  with  blood  and  great  diffi- 
culty in  finding  the  bleeding  point,  thus  causing  risks  of  including  in 
the  ligature  or  otherwise  injuring  important  parts,  such  as  the  recur- 
rent laryngeal. 

2.  Injury  to  the  recurrent  laryngeal  nerve,  asphyxia,  aphonia. 
This  most  grave  accident  has  happened  with  sufficient  frequency  to 
put  any  surgeon  on  his  guard.  The  injury  may  be  due  to  including 
the  nerve  in  a  ligature,  cutting  the  nerve,  or  seriously  bruising  it. 
Richelot,t  writing  in  1885,  found  nine  cases  in  which  it  was  certain 
that  the  recurrent  laryngeal  had  been  cut  during  the  operation.  He 
gives  the  following  causes  of  aphonia  after  the  operation  :  (1)  Wound 
of  inferior  laryngeal  nerve;  (2)  dragging  of  this  nerve;  (3)  perhaps 
section  of  the  crico-thyroid  branch  of  the  superior  laryngeal;  (4) 
months  after  ojieration  it  may  come  on  from  exclusion  of  the  inferior 

*  The  following  is  the  advice  of  Billroth  on  this  matter:  "Large  prominent  bron- 
choceles in  people  above  forty  years  of  age,  with  slight  or  no  dyspnoja,  should  not  be 
operated  on  just  for  the  sake  of  appearance.  I  think  that  small  bronchoceles  con- 
nected to  the  lower  part  of  the  thyroid  in  children  and  young  people  should  be  more 
often  removed,  especially  when  their  situation  is  such  that  the  tumor  might,  with  tiie 
increased  growth,  possibly  entail  some  danger." 

t  L' Union  Med.,  Nos.  17  and  18,  1885  ;  Med.  Chron.,  June,  1885. 


OPERATIONS    ON    THE   THYROID    GLAND.  389 

laryngeal  nerve  in  the  cicatrix  ;  (5)  when  the  laryngeal  symptoms  are 
progressive  from  ascending  neuritis  (Schwartz).  This  may  be  present 
before  the  operation,  and  so,  too,  may  be  (6)  compression  of  the  infe- 
rior laryngeal  by  the  goitre. 

M.  Richelot,  after  discussing  the  results  of  section  and  irritation  of 
the  recurrent  laryngeal,  thinks  that  the  sudden  dyspnoea  and  aphonia 
must  be  attributed  to  division  of  the  recurrent  with  irritation  of  the 
upper  end. 

Whatever  the  exact  cause  is,  it  is  certain  that  the  dyspnoea  and 
aphonia  are  not  always  permanent.  As  bearing  on  these  points,  the 
two  following  cases  of  INI.  Richelot  are  of  much  interest :  * 

In  a  woman  of  twenty-five,  suffering  from  suffocating  dyspncea,  the 
operation  was  followed  by  aphonia,  which  lasted  for  three  months, 
and  by  complete  paralysis  of  the  cords.  The  operation  was  performed 
with  great  care,  and  there  is  no  reason  to  think  that  either  of  the 
recurrents  was  cut,  but  it  is  possible  that  they  were  bruised  or  stretched  ; 
however,  in  four  months  the  cords  regained  movement  and  the  voice 
was  fully  restored. 

In  the  second  case,  aged  twenty,  a  hard  mobile  tumor,  the  size  of  a 
walnut,  was  attached  to  the  isthmus  by  a  narrow  pedicle,  and  the 
gland  itself,  though  apparently  somewhat  hypertrophied,  was  not 
prominent.  But,  when  exposed,  it  was  found  that  the  tumor  had  a 
broad  attachment  to  the  isthmus,  and  that  the  two  lobes  of  the  thyroid 
were  greatly  hypertrophied,  closely  embracing  and  compressing  the 
trachea;  it  was  therefore  thought  desirable  not  only  to  snip  off  the 
tumor,  but  to  dissect  out  and  to  remove  the  whole  gland.  When 
recovering  from  the  effects  of  chloroform,  the  patient  was  suddenly 
seized  with  cyanosis  and  threatening  asphyxia,  and  though  she  par- 
tially recovered,  on  the  next  day  there  was  aphonia,  dysphagia,  and 
uninterrupted  dyspnoea,  and  she  died  asphyxiated  in  the  evening. 
Both  recurrent  laryngeals  had  been  cut,  and  the  upper  end  of  the  left 
one  was  included  in  a  ligature. 

Injury  to  the  nerve  is  especially  likely  to  occur  under  the  following 
conditions :  (a)  when  the  growth  is  huge  ;  (b)  when  it  is  very  fixed  by 
adhesions  (which  are  uncommon),  or  by  a  broad  base;  (c)  when  it  is 
ill-defined  ;  (d)  when  it  encircles  the  trachea  and  oesophagus  closely; 
(e)  when  it  is  malignant. 

3.  Septic  cellulitis  leading  to  purulent  and  diffused  mediastinitis. 
These  are  very  likely  if  the  wound  becomes  septic.  In  such  cases  th-e 
latter  complication  is  almost  certain,  even  in  small  goitres^  if  they  dip 
down  behind  the  sternum,  owing  to  the  difficulty  of  providing  ade- 
quate drainage.     The   accompanying   symptoms   are :     Pain  in  the 

*  With  them  the  case  I  liave  given  at  p.  404  may  be  referred  to. 


390  OPERATIONS   ON    THE    HEAD    AND    NECK. 

region,  coming  on  soon  after  the  operation  and  increasing,  followed 
by  feebleness  of  the  pulse,  distress,  and  dyspnoea,  and  speedy  death. 

4.  Myx(Bderaa,  both  acute  and  more  deferred.  This  strange  con- 
dition, which  has  so  unexpectedly  overclouded  otherwise  successful 
operations  for  complete  removal  of  an  enlarged  thyroid  gland,  was 
first  noticed  and  published  by  two  Swiss  surgeons,  Kocher  and  Rev- 
erdin.*  The  correct  explanation  will  probably  be  found  to  be  the 
one  which  Prof  Horsley  brought  before  the  profession  in  his  lucid 
and  convincing  Brown  lectures  of  ISSo.f  The  issues  here  treated  are 
so  wide,  the  experimental  researches  are  so  complete  and  far-reaching, 
that  any  abstract  must,  unintentionally,  seem  to  do  them  an  injustice. 
The  following  are  the  points  of  chief  importance  to  the  operating 
surgeon  : 

Effects  of  Excision.  Phenomena  following  Complete  Thyroidectomy  in 
Monkeys. — "At  a  variable  period  after  the  operation,  but  averaging  five 
days,  the  animal  is  found  to  have  lost  its  appetite  for  a  day  or  two, 
and,  on  closer  examination,  to  exhibit  slight  constant  fibrillar  tremors 
in  the  muscles,  of  the  face  and  hands  and  feet  more  especially.  These 
tremors  disappear  at  once  on  voluntary  effort.  At  the  same  time  the 
animal  is  noticed  to  be  growing  pale  and  thin,  in  spite  of  the  appetite, 
etc.,  returning  quickly  with  great  increase;  ra])idl_y  the  tremors  in- 
crease, affect  all  the  muscles  of  the  body  without  exception,  the 
animal  becomes  languid,  paretic  in  its  movements,  and  imbecile. 
Then  puffiness  of  the  eyelids  and  swelling  of  the  abdomen  follow, 
with  increasing  hebetude.  During  these  last  stages  the  temperature, 
gradually  falling,  becomes  subnormal,  and  then  the  tremors  disappear 
as  they  came.  Meanwhile  the  pallor  of  the  skin  often  becomes 
intense,  and,  leucocytosis  having  been  well  marked,  oligtemia  follows, 
and  the  animal  dies  perfectly  comatose  in  a  variable  period,  but 
usually  about  five  or  seven  weeks  after  the  operation." 

Post-mortem  Appearances  met  ivith  after  Complete  Thyroidectomy. — Prof. 
Horsley  thus  sums  these  up  :  "Ablation  of  the  thyroid  causes  atrophic 
changes  in  the  central  nervous  system,  and  in  the  fat  generally.  It 
causes  an  increase  in  the  general  connective  tissue,  and  a  mucoid  con- 
version of  the  ground  substance.  This  increase  of  mucin  in  the 
connective  tissue  is  accompanied  by  an  extraordinary  secretion  of  the 
same  stuff  by  means  of  the  salivary  glands,  and  also  those  of  the  ali- 
mentary canal." 

*  Arch.f.  Klin.  Chir.,  Bd.  xxix.  p.  254,  1883. 

t  Brit.  Med.  Journ.,  January  17  and  31, 1885  :  "  The  Thyroid  Gland  :  its  Relation 
to  the  Pathology  of  Myxoedema  and  Cretinism  ;  to  the  Question  of  the  Surgical  Treat- 
ment of  Goitre ;  and  to  the  General  Nutrition  of  the  Body." 


OPERATIONS   ON    THE   THYROID    GLAND.  391 

While  these  changes  are  going  on,  the  hsemapoietic  tissues,  especially 
the  spleen,  are  found  to  have  undergone  obvious  compensatory 
hypertrophy. 

Theories  explaining  Myxoedema,  Cachexia  Strumipriva,  and  Cretinism. 

Prof.  Horsley  discussed  the  three  following,  maintaining,  himself, 
the  third  to  be  the  correct  one  : 

i.  Kocher's  view,  that  the  symptoms  of  myxoedema  which  follow 
complete  thj'roidectomy  are  brought  about  by  chronic  asphj^xia,  due 
to  narrowing  of  the  trachea,  conse(iuent  on  softening  and  atrophy, 
produced  by  ligature  of  the  thyroid  vessels  which  supply  the  trachea 
and  oesophagus  as  well.  Prof.  Horsley  finally  disposes  of  this  view 
by  remarking  that  there  are  numerous  cases  of  marked  stenosis  of  the 
larynx  and  trachea  on  record,  but  not  a  symptom  of  myxoedema  has 
here  been  noticed.  Furthermore,  in  his  experimental  thyroidectomies, 
the  larynx  and  trachea  were  found  absolutely  normal  and  patent. 

11.  Dr.  Hadden's  views  that  the  myxoedematous  state  of  malnutrition 
is  brought  about  by  a  general  spasm  of  the  arterioles  and  ca23illaries, 
the  spasm  being  maintained  by  central  disturbance  in  the  sympathetic 
ganglia.  This  view  regards  the  atrophy  of  the  thyroids  as  due  to 
constriction  of  the  bloodvessels,  and  therefore  of  secondary  impor- 
tance. It  has  been  accepted  by  Kocher  on  the  assumption  that  in  the 
operation  the  sympathetic  nerves  are  injured  and  irritated  by  being 
Included  in  the  ligatures  placed  on  the  vessels.  It  is  set  aside  by 
Prof  Horsley  because  (a)  it  has  been  found  experimentally  that  if  the 
gland  be  exposed,  and  the  nerves  going  to  it  are  divided,  the  symp- 
toms of  myxoedema  do  not  appear;  (,5)  in  Prof.  Horsley 's  experi- 
mental thyroidectomies  which  were  followed  by  myxoedema,  the 
Irritation  of  the  nerves  was  only,  he  considers,  momentary,  (y)  The 
sympathetic  trunk  and  ganglia  appear  to  be,  microscopically,  abso- 
lutely normal. 

iii.  The  theory*  that  the  four  varieties  of  a  general  state  of  mal- 
nutrition, given  below-,  are  due  to  the  loss  of  function  of  the  thyroid 

*  Prof.  Horsley  also  deals  with  some  objections  which  liave  been  raised  to  his  theory 
— (1)  Even  if  in  the  above-named  conditions — viz.,  cretinism,  myxtedema,  cachexia 
strumipriva,  and  cachexia  after  thyroidectomy,  a  thyroid  body  be  discovered  post- 
mortem, it  does  not  follow  that  this  was  in  full  normal  function.  (2)  If  one  lobe  be 
excised,  the  other  hypertrophies;  if  this  enlarged  half  be  now  removed,  the  animal 
presents  many  of  the  symptoms  described.  In  answer  to  the  statement  of  SchifT  that, 
provided  an  interval  of  about  three  weeks  elapses  between  the  operations,  the  symp- 
toms do  not  appear,  or,  at  any  rate,  are  not  fatal,  Prof.  Horsley  replies  that  even  if  the 
above  observation  is  to  be  trusted  the  mitigation  of  symptoms  can  readily  be  under- 
stood, as  the  spleen  will  have  had  time  to  provide  for  the  haemapoietic  functions  of  the 
gland. 


392  OPERATIONS   ON    THE    HEAD    AND    NECK. 

gland,  perhaps  through  disturbance  of  the  nervous  centres,  leading  to 
vaso-niotor  or  trophic  changes  in  the  tissues.* 

The  following  cases,  with  the  results  of  operation,  support  Prof. 
Horsley's  views.  They  might  be  multiplied  by  other  published  cases, 
and  it  is  probable  that  many  other  temporarily  successful  thyroidec- 
tomies have  been  followed  by  myxoedema,  ])ut  that  this  ending  of  the 
cases  has  not  been  made  known. 

Volkovitch,  of  Kiev,t  removed  the  whole  gland  in  a  woman  aged 
thirty-eight,  for  dyspnoea  and  dysphagia  indicating  operative  inter- 
ference. Death  took  place  four  months  after  the  operation,  Avith 
marked  evidence  of  cachexia  strumipriva — i.e.,  ansemia  and  weakness, 
tetany  of  hands  and  legs  setting  in  five  days  after  the  operation,  and 
becoming,  later  on,  more  general,  numbness  of  hands,  myxoedema- 
tous  condition  of  the  integument,  striking  apathy,  difficulty  in  articu- 
lation and  respiration. 

Sir  W.  Stokes  I  has  published  a  case  in  which  a  somewhat  similar 
fatal  result  followed  complete  thyroidectomy.  A  healthy  w^oman, 
aged  eighteen,  was  admitted  with  extensive  enlargement  of  both  thy- 
roid lobes,  causing  urgent  dyspna?a,especially  at  night.  It  was  found 
impossible  to  remove  more  than  the  left  lobe,  owing  to  the  profuse 
haemorrhage,  which  proved  almost  fatal.  A  good  recovery  took  place, 
followed,  for  a  while,  by  relief  of  dyspnea  and  diminution  in  the  size 
of  the  right  lobe.  In  about  six  weeks,  however,  the  right  lobe  was  as 
large  as  before,  and  the  thrill  and  dyspnoea  were  again  present  in  an 
intensified  form.     The    right  "lobe  w^as   removed  with  even  greater 

*  Prof.  Horsley  thus  tabulates  the  most  striking  of  the  anatomical  and  physiological 
facts  bearing  upon  experimental  myxoedema : 

"  1.  The  thyroid  gland  appears  to  consist  of  two  distinct  portions — (a)  glandular, 
consisting  of  highly  vascular  acini,  which  excrete  into  their  interior  a  mucoid  sub- 
stance, this  substance,  or  something  closely  similar,  being  found  in  the  lymph-vessels 
of  the  gland — mucin-excreting  function?  (6)  highly  vascular,  lymphoid  nodules — 
hsematogenous  function. 

"  2.  Excision  of  the  gland  is  followed,  according  to  my  experiments,  by  an  increase 
in  the  amount  of  mucin  in  the  tissues  which  normally  possess  it,  by  a  retrograde  his- 
tological change,  by  an  increase  in  the  activity  of  the  glands  which  normally  excrete 
it,  and,  what  is  still  more  striking,  by  the  assumption  of  the  muciparous  function  by  a 
gland  which  normally  produces  none,  or  very  little,  mucin — the  parotid  gland. 

"3.  Excision  of  the  gland  is  followed  by  profound  changes  in  the  blood — namely,  a 
diminution  of  the  number  of  corpuscles,  preceded,  as  regards  the  number  of  the  white 
elements,  by  a  temporary  increase  in  their  number,  by  an  alteration  in  the  coagula- 
bility and  albumins,  and  by  an  abnormal  presence  of  mucin. 

"4.  Excision  of  the  gland  is  followed  by  nerve-symptoms  indicating  changes  in  the 
lowest  motor  centres,  these  changes  causing  tremors,  with  rigidity  and  paresis;  it  is 
also  followed  by  changes  in  the  higher  psycho-cortical  centres,  such  producing  imbe- 
cility, and,  ultimately,  death  in  the  comatose  state." 

t  Lond.  Med.  Record,  April  15,  1885,  p.  148. 

X  Brit.  Med.  Journ.,  October  16,  1888. 


OPEEATIONS    ON    THE   THYROID   GLAND.  393 

danger  from  syncope.  Within  a  fortnight  convulsive  seizures  set  in, 
and  fatty  swellings  were  noticed  about  the  eyelids,  backs  of  the  wrists, 
and  over  the  metatarsi.  Mental  torpor  also  appeared,  and  the  aspect 
of  the  face  became  gradually  one  of  imbecility.  The  convulsive 
seizures  recurred,  with  lividity  of  the  face,  stertor,  dyspna?a,  protrusion 
of  eyes,  dilatation  of  the  pupils,  and  throbbing  of  the  carotids,  fol- 
lowed by  copious  perspiration.  The  patient  became  weaker  and  died, 
with  symptoms  of  pulmonary  infiltration,  ten  days  after  the  second 
operation.  The  very  brief  account  uf  the  post-mortem  only  mentions 
the  brain,  heart,  and  lungs;  of  these,  the  two  former  "contained 
nothing  abnormal ;  the  lungs  were  highly  oedematous." 

Mikulicz,  of  Cracow,*  states  that  the  published  cases  of  cachexia 
strumipriva  after  thyroidectomy  already  number  thirty-five,  and  he 
adds  another.  As  to  other  evils  which  may  result  from  total  thyroid- 
ectomy, he  says  that  Weiss,  in  1883,  found  thirteen  cases  of  tetany, 
and  Mikulicz  himself  has  had  four  cases  in  seven  operations.  He  also 
cites  three  cases,  two  of  his  own,  in  which  epileptic  convulsions  fol- 
lowed total  extirpation. 

It  is  right  to  state  that  other  observers  have  failed  to  trace  the  above 
sequence.  Foremost  amongst  these  is  the  experience  of  Billroth,  who, 
in  1883,  had  performed  extirpation  sixty-eight  times,  with  a  mortality 
of  only  7.3  per  cent.,  and  without  once  observing  cachexia  strumi- 
priva. Crede,  of  Dresden  {Congress  of  German  Surgeons,  1884),  reported 
fourteen  cases  of  comiDlete  extirpation  without  one  case  of  myx- 
cedema  following. 

Sir  W.  MacCormac  (Brit.  Med.  Jour.,  1884,  vol.  ii.  p.  231)  mentions, 
in  explanation  of  Kocher's  results,  the  opinion  of  Bardleben,  "  that 
the  cretinoid  condition  observed  by  Kocher  may  very  well  have  fol- 
lowed in  his  cases,  irrespective  of  the  extirpation  of  the  gland,  and 
that  the  enlarged  thyroid  was  but  a  link  in  the  chain  of  symptoms, 
dependent  rather  on  the  locality  from  which  the  patient  came,  than 
on  the  circumstance  that  extirpation  of  the  goitre  had  been  prac- 
ticed." 

However  this  matter  may  finally  be  cleared  up,  the  fact  remains 
beyond  dispute  that  in  many  parts  of  Europe  symptoms  akin  to  those 
of  myxoedema  have  followed  complete  thyroidectomy,  especially  in 
young  subjects.!  Why  this  sequence  has  not  been  invariable,  and  what 
the  explanation  of  it  is  when  it  does  appear,  is  as  yet  uncertain.  But, 
till  this  matter  is  cleared  up,  I  am  distinctly  of  opinion  that  complete 
extirpation  of  the  thyroid  is  as  yet  unjustifiable.     It  is  certainly  an 

*  Brit.  Med.  Journ.,  October  16,  1886 

f  Of  Koclier's  sixteen  cases,  in  which  cachexia  strumipriva  was  developed,  nine 
were  under  twenty  years  of  age,  five  between  twenty  and  thirty,  and  only  two  above 
thirty.     Eleven  were  young  women  ;  five  were  males. 


394  OPERATIONS    ON    THE    HEAD    AND    NECK. 

operation  of  many  nndoubted  risks,  such  as  haemorrhage,  injury  to 
the  recurrent  hiryngeal  and  the  trachea,  and  septic  trouble.  In  addi- 
tion, the  great  risk  of  myxedema  remains,  an  uncertainty  perhaps, 
but  still  to  be  reckoned  with.  On  the  other  hand,  we  have  operations 
which  are  infinitely  safer,  such  as  ligature  and  removal  of  the  isthmus 
and  removal  of  one-half,  to  be  followed,  if  needful,  by  ligature  of  the 
arteries  to  the  opposite  half  later  on. 

Operation  for  Removal  of  One-Half,  and  tlie  Isthmus 

as  well,  if  required.— The  parts  having  been  cleansed,  and  the 
patient's  head  and  shoulders  conveniently  supported,  the  surgeon 
makes  a  free  incision  over  the  most  prominent  part  of  the  tumor 
which  he  is  going  to  remov^e,  avoiding  any  large  veins.  An  ample 
longitudinal  incision  *  will  nearly  always  give  all  the  room  that  is 
required,  and  such  a  scar  will  be  little  conspicuous,  falling,  as  it  does 
eventually,  into  the  sulcus  just  internal  to  the  sterno-mastoid,  a  point 
of  much  imj^ortance  in  women. 

The  skin  and  platysma  being  cut  through,  any  superficial  veins 
carefully  tied,  the  deep  ftiscia  is  slit  up  and  the  gland  itself  exposed, 
bluish-red  and  with  large  veins  on  its  surface.  Spread  also  over  this 
are  often  one  or  more  of  the  depressors  of  the  hyoid  bone;  these  are 
separated  with  a  blunt  dissector,  or,  if  needful,  divided  between  silk 
ligatures.  One  or  more  large  retractors  are  now  inserted  so  as  to 
draw  outwards  the  sterno-mastoid  and  large  vessels,  while  the  surgeon 
with  his  left  index  finger,  or  a  blunt  dissector,  frees  the  enlarged  part 
of  the  thyroid  from  its  bed,  shelling  it  forwards,  and  probably  finds 
it  only  fixed  above,  below,  and  internally,  by  the  thyroid  vessels  and 
the  isthmus.  In  effecting  this  separation,  the  greatest  care  must  be 
taken  to  work  gently  and  to  keep  close  to  the  tumor,t  the  veins  being 
often  much  enlarged  and  thin-walled.J     The  upper  extremity  of  the 

*  Tlie  incision  can  either  be  made  as  above,  laterally,  or  it  may  be  angular  with  a 
straight  limb  in  the  median  line  from  hyoid  to  sternnni,  and  one  passing  obliquely 
outwards  and  upwards  from  the  upper  end  of  the  first.  If  the  surgeon  still  persist  in 
removing  the  whole  gland,  the  incision  may  be  Y"shaped.  In  cases,  as  in  that  of  Sir 
W.  MacCormac  {Inc.  supra  cit.),  where  the  skin  is  adherent  after  the  use  of  setons,  etc., 
the  incisions  must  be  iiiade  so  as  to  enclose  and  remove  the  adherent  skin  and  cica- 
trices. 

t  The  capsule  of  the  tumor  ni\ist  nowhere  be  opened.  Such  a  step  not  only  leads  to 
flooding  of  the  wound  with  blood,  but  thus  also  obscures  and  may  lead  to  damage  of 
important  parts — e.g.,  the  recurrent  laryngneal  and  trachea. 

t  While  it  is  quite  impossible  to  give  any  adequate  idea  of  the  number  of  vessels 
which  may  be  met  with  in  a  large  and  difficult  case,  it  will  be  well  to  recall  the  prin- 
cipal vein-trunks.  The  superior  thyroid  vessels  enter  at  the  upper  angle;  a  little 
below  these  emerges  laterally  a  superior  accessory  vein  (Kocher).  The  same  surgeon 
describes  as  constant  a  superior  and  inferior  communicating  vein  as  lying  above  and 
below  the  isthmus,  the  former  joining  the  two  superior  thyroids,  and  the  latter  entering 


OPERATIONS   ON   THE   THYROID    GLAND.  395 

tumor  being  first  isolated,  the  superior  thyroid  vessels  are  found  and 
tied  with  double  ligatures  of  chromic  catgut  or  carbolized  silk  passed 
with  an  aneurism  needle.  This  effected,  the  tumor  is  next  isolated  in 
a  downward  direction,  and  any  outlying  masses  turned  out  from 
beneath  the  sterno-mastoid.  The  next  step  usually  taken  is  similar 
isolation,  ligature,  and  division  of  the  inferior  thyroids,  but  the  writer 
prefers  to  take  the  isthmus  next,  being  of  opinion  that  the  more  the 
growth  is  freed  and  isolated,  and  the  less  fixed  it  is,  the  more  easily 
are  the  inferior  thyroid  vessels  dealt  with,  and  the  less  danger  is  there 
of  damaging  the  recurrent  laryngeal. 

The  separation  of  the  isthmus  is  best  effected  with  a  steel  director, 
care  being  taken  to  keep  the  isthmus  as  much  off  the  trachea  as  possi- 
ble, and  the  point  of  the  director  close  to  the  isthmus.  When  this 
body  has  been  sufficiently  separated,  it  may  be  ligatured  after  trans- 
fixion with  an  aneurism  needle  carrying  carbolized  silk  or  strong 
chromic  gut,  or  it  may  be  carefully  torn  through  with  the  point  of  a 
director,  and  each  bleeding-point  secured."^  The  amount  of  haemor- 
rhage met  with  in  detaching  and  dividing  the  isthmus  varies  very 
much.  If  the  separating  is  effected  piecemeal,  the  bleeding  is  often 
very  slight.  This  is  probably  accounted  for  by  the  fact  that  the 
intimacy  of  connection  and  continuity  of  structure  between  the  halves 
of  the  thyroid  and  the  isthmus  varies  much  also ;  in  many  cases  the 
connection  is  mainly  by  connective  and  a  little  glandular  tissue,  with 
very  few  vessels. 

The  tumor,  now  almost  completely  isolated,  is  drawn  to  one  side, 
and  especial  care  is  taken  before  ligaturing  the  inferior  thyroid  vessels. 
These  should  be  most  carefully  isolated  and  inspected,  so  as  to  avoid 
injur}^  to,  or  including,  the  recurrent  laryngeal.  Owing  to  the  fact 
that  the  trunk  of  the  inferior  thyroid  artery  does  not  come  into  rela- 
tion with  the  recurrent  laryngeal  till  both  are  close  to  the  trachea,  the 
vessel  should  be  ligatured  and  cut  at  some  distance  from  it. 

If  the  vessel  is  tied  at  all  en  masse,  the  nerve  may  very  likely  be  in- 

into  the  thyroidea  ima  vein.  The  inferior  thyroid  vessels  pass  behind  the  outer  border 
of  the  tliyroid,  and  for  some  distance  behind  it,  before  penetrating  it  with  its  several 
brandies.  A  little  above  the  inferior  thyroid  vessels  emerges  the  inferior  accessory 
thyroid  vein.  The  anterior  jugular  will  have  to  be  dealt  with,  and  the  positions  of 
the  internal  jugular,  and,  below,  of  the  innominate  veins,  will  have  to  be  remembered 
in  the  case  of  huge  tumors.  The  above  veins  are  figured  by  Sir  W.  MacCormac  {loc. 
supra  cit.)  in  an  illustration  taken  from  Kocher. 

*  If  the  pedicle  seem  too  thick  and  vascular  to  treat  in  this  way,  which  may  be  the 
case  in  colossal  bronchoceles,  it  should  be  subdivided  and  tied  in  several  pieces,  like  a 
stout  ovarian  pedicle.  If  this  cannot  be  managed,  and  if  the  patient's  condition  admits 
of  it,  the  pedicle  may  be  divided  by  an  ^craseur,  or  seared  through  with  the  cautery. 
In  such  case  the  stump  should  be  brushed  over  with  a  strong  solution  of  zinc  chloride, 
dusted  with  iodoform,  and,  if  possible,  brought  outside  the  wound. 


396  OPERATIONS    ON    THE    HEAD    AND    NECK. 

eluded,  and  the  same  risk  is  run  if  at  this  stage  the  wound  is  not  kept 
dry  and  bloodless. 

Baumgartner  of  Baden,  and  Crede  of  Dresden  (quoted  by  Sir  W. 
MacCormac,  he.  supra  cit.),  lay  stress  upon  the  importance  of  tying 
the  branches  of  the  inferior  thyroid  close  to  the  gland  itself,  thus 
avoiding  any  risk  of  tying  the  recurrent  laryngeal  nerve  and  of  injur- 
ing the  small  vessels  to  the  trachea,  oesophagus,  and  larynx.  Sir  W. 
MacCormac  also  approves  of  this  plan. 

After  the  removal  of  the  tumor,  the  wound  should  be  examined  for 
any  bleeding-points,  adequate  drainage  then  provided,  and  the  wound 
carefully  closed,  save  below,  to  allow  of  free  escape  of  discharges  here, 
and  thus  to  avoid  any  risk  of  burrowing,  and  mediastinal  cellulitis. 

If  during  the  operation  there  is  any  evidence  of  syncope,  tlie  head 
should  be  lowered  and  injections  of  ether  or  brandy  given.  Both  the 
surgeon  and  the  assistant  who  is  giving  the  anaesthetic  must  be  on  the 
look-out  for  evidence  of  dyspnrea  or  asphyxia.  If  any  evidence  of  it 
occur,  it  is  an  indication  for  the  surgeon  most  carefully  to  examine 
the  tissues  which  he  is  handling,  and  the  amount  to  which  he  may  be 
dragging  upon  the  air-passages  in  the  manipulation  of  the  tumor. 
Tracheotomy  seems  nearly  always  to  be  a  fatal  complication,*  partly 
by  rendering  such  a  deep  and  important  wound  septic,  partly  by 
causing  septic  broncho-pneumonia,  and  partly  by  adding  to  the  shock 
in  a  patient  already  collapsed  by  so  severe  an  operation. 

If  tracheotomy  appear  urgently  needed,  the  surgeon  should  try 
first  slitting  up  more  freely  tlie  deep  cervical  fascia  or  dividing  or 
retracting  any  stretched  muscles,  in  order  to  relieve  the  trachea  and 
breathing. 

In  the  event  of  the  operation  having  to  be  performed,  great  difficul- 
ties must  be  expected,  and  the  surgeon  should  be  provided  with  long 
soft  tubes,  in  case  there  is  any  mediastinal  prolongation  pressing  upon 
the  lower  part  of  the  trachea.  Every  possible  attention  must  be  paid 
to  keeping  the  tracheotomy  wound  sweet  with  applications  of  iodo- 
form, iodoform  and  ether,  etc.  Sir  W.  MacCormac  draws  attention  to 
the  need  of  keeping  the  head  very  steady  at  the  time  of  the  tra- 
cheotomy, and,  later  on,  with  sand-bags  ;  he  advises  leaving  the  thy- 
roidectomy wound  open  and  treating  it  with  frequent  irrigation,  if 
tracheotomy  has  been  found  necessary. 

For  the  first  few  days  after  thyroidectomy,  care  must  be  taken  to 
keep  the  dressings  securely  in  position.  This  is  especially  difficult  in 
a  mobile  part  like  the  neck,  which  does  not  admit  of  compression. 
The  safest  plan  is  to  pass  the  gauze  bandages  under  the  axilla?  below, 

*  In  five  of  Billroth's  cases  in  which  tracheotomy  was  performed  tiiree  died. 
Kocher's  experience  has  been  the  same. 


OPERATIONS   ON    THE   THYROID   GLAND.  397 

and,  above,  to  wind  them  over  the  chin  and  forehead,  points  of  friction 
being  carefully  packed  with  salicylic  wool,  and  all  made  secure  by 
stitching.     This  alone  will  keep  the  dressings  from  slipping  down. 

Unless  primary  union  is  secured  throughout,  any  silk  ligatures 
used  are  liable  to  come  away  for  man}^  months.  Thus,  Sir  W.  Mac- 
Cormac  (loc.  swpra  cit.)  relates  a  case  of  thyroidectomy  lasting  two 
hours,  in  which  at  least  a  hundred  ligatures  were  used.  Six  months 
later  a  sinus  was  still  discharging  ligature-threads.* 

Question  of  Operation  in  Cases  of  Malignant  Disease 

of  the  Thyroid. — The  surgeon  must  consider  here  most  carefully 
whether  any  operation  is  justifiable.  In  the  first  place  the  risk  of 
injury  to  the  recurrent  laryngeal  is  much  increased  from  the  tendency 
of  a  malignant  growth  to  creep  round  the  trachea,  dip  into  the  sulci 
between  the  large  vessels  and  the  windpipe,  and  to  infiltrate  important 
parts.  Secondly,  these  growths,  especially  if  rapid,  tend  to  creep 
down  into  the  anterior  mediastinum,t  behind  the  sternum.  Thirdl}^, 
in  addition  to  these  dangers,  must  be  considered  that  of  glandular 
invasion, I  and  the  doubtfulness  of  getting  all  the  growth  away,  and 
the  increased  risks  of  hemorrhage  and  cellulitis. 

Dr.  Rotter  {Arch.f.  Clin.  Chir.,  Bd.  xxxi.  Heft  4  ;  Year-book  of  Treat- 
ment, 1885,  p.  138)  gives  details  of  fifty  cases  of  cancer  of  the  thyroid 
submitted  to  operation.  Of  these  eight  died  in  the  first  twenty-four 
hours,  five  at  the  end  of  the  first  week,  and  eight  at  the  end  of  the 
second  week.  Only  four  patients  remained  free  from  a  recurrence  at 
the  end  of  six  months.  These  figures  point  very  strongly  to  the  con- 
clusion that  in  malignant  disease  of  the  thyroid  an  operation  is  most 
rarely  justifiable. 

Mr.  Butlin  {Operat.  Treat,  of  Mallg.  Dis.,  p.  206)  thinks  that  "at 
present  the  number  of  instances  in  which  a  cure  of  the  disease  can  be 
claimed  is  so  small  §  that  the  oiDcration  is  scarcely  justified."     The 

*  See,  on  this  point,  the  footnote,  p.  404. 

f  A  remarkable  instance  of  malignant  bronchocele  is  figured  by  Billroth  [Clin. 
Surg.,  pi.  ii.  and  iii.).  It  was  a  soft  carcinoma,  and  extended  down  behind  the  sternum, 
compressing  the  right  innominate  vein,  and  causing  enormous  dilatation  of  the  super- 
ficial veins  of  the  neck  and  front  of  the  trunk. 

X  E.g.,  Cervical,  mediastinal,  bronchial. 

^  He  thus  analyzes  the  cases  in  the  paper  by  Dr.  Rotter,  quoted  above,  and  two 
others  by  Dr.  Rose  and  Dr.  Braun  (Langenbeck's  Arch.,  1879,  1883).  Of  fifty  cases 
submitted  to  operation  thirty  were  fatal.  Of  the  twenty  which  survived  the  operation, 
a  recurrence  took  place  in  ten,  which  was  either  fatal  or  promised  rapidly  to  be  so.  In 
two  the  operation  was  abandoned  In  three  the  further  liistory  was  not  known,  and 
in  one  it  only  extended  to  a  period  of  two  months  after  the  operation.  In  four  only 
was  a  result,  which  Mr.  Butlin  courteously  calls  favorable,  obtained.  One,  a  patient 
of  Bircher's,  was  well  eleven  months  after  operation.  In  tlie  second,  Bruns  removed 
some  enlarged  glands  a  year  after  the  first  operation,  and  two  and  a  quarter  .years  later 


398  OPERATIONS   ON    THE    HEAD    AND    NECK. 

following  facts,  to  which  Mr.  Butlin  draws  attention,  are  worthy  of 
careful  notice  :  (1)  The  large  number  of  cases  in  which  secondary 
afifection  was  discovered  at  the  autopsy,  even  when  death  occurred 
within  a  few  days  after  the  operation  ;  (2)  The  frequency  with  which 
it  was  found  impossible  to  entirely  remove  the  tumor  ;  (3)  The  diffi- 
culty of  diagnosis  in  the  early  stage  of  malignant  disease  of  the  thy- 
roid. The  chief  points  which  should  be  looked  to  here  are  early  fixity 
and  irregularity  of  outline,  to  which  Mr.  Butlin,  quoting  from  Rose, 
adds  continuous  growth  *  and  marked  dysphagia. 

Treatment  of  Enlarged  Thyroid  by  Operations  on  the 

Isthmus. — This  method  consists  in  excising  the  isthmus  after  apply- 
ing double  ligatures,  or  in  trusting  to  double  ligatures  alone.  It  was 
first  recommended  in  this  country  by  Sir  D.  Gibb,t  and  has  more  re- 
cently been  used  and  advocated  by  Mr.  Sydney  Jones. 

In  Sir  D.  Gibb's  cases  the  patients  were  young  women  whose  bron. 
choceles  had  resisted  other  treatment.  In  one  case  there  was  general 
enlargement  of  the  thyroid,  especially  on  the  right  side,  the  isthmus 
could  be  felt,  distinctly  rounded,  and  projecting  somewhat  over  the 
trachea.  Mr.  Holthouse  exposed  the  isthmus,  and,  after  placing  a 
ligature  on  either  side,  removed  it.  About  six  months  later  the  patient 
was  entirely  free  from  her  old  symptoms— tension,  dyspnea,  etc., — 
and  the  lobes  appeared  to  have  receded  laterally,  and  to  be  less 
prominent. 

In  the  second  case  there  was  much  enlargement  of  the  veins  owing 
to  extension  downwards  of  the  bronchocele.  Cough,  dysphagia,  and, 
at  times,  urgent  dyspnoea  were  present.  When  Mr.  Holthouse 
exposed  the  isthmus  it  suddenly  cropped  up  like  a  hernial  tumor. 
After  cautiously  detaching  it  with  curved  scissors,  two  ligatures  were 
passed  under  it  as  widely  apart  as  possible.  As  they  seemed  likely  to 
become  detached  if  the  isthmus  was  cut  away,  they  were  left  in  to 
slough  out.  The  patient  made  a  good  recovery  with  much  relief  to 
her  symptoms. 

A  very  interesting  case  has  been  recorded  by  Mr.  Sydney  Jones  :  J 

the  patient  died  of  inflammation  of  the  hmgs.  The  tiiird,  a  patient  of  Maas',  was  re- 
ported to  be  quite  well  nearly  four  years  after  the  operation ;  and  the  fourth,  under  the 
same  surgeon,  died  in  twelve  months  of  some  uncertain  lung  affection. 

*  Kose  has  pointed  out  that  the  surgeon  is  liable  to  be  deceived  on  this  point  by  the 
eflfect  of  remedies.  Thus,  potassium  iodide  may  cause  a  diminution  in  the  size  of  the 
neck,  a  fact  which  may  be  attributed  to  the  efi'ect  of  the  drug  on  the  general  enlarge- 
ment of  the  gland,  which  is  frequently  associated  with  the  occurrence  of  more  or  less 
limited  malignant  disease.  Attention  has  already  been  drawn  at  pp.  326,  370  of  this 
book  to  the  procrastination  (sometimes  pernicious  in  its  results)  which  this  temporary 
result  of  giving  potassium  iodide  may  bring  about  in  malignant  disease. 

t  Lancet,  1875,  vol.  i.  p.  120. 

X  Lancet,  November  24,  1883,  p.  900. 


OPERATIONS   ON   THE   THYROID    GLAND.  399 

The  patient,  aged  eighteen,  had  noticed  the  SAveUing  ahout  eight 
3^ears,  latterly  it  had  increased  rapidly.  The  dyspnoea  was  marked, 
the  least  exertion  bringing  on  paroxysms.  The  thyroid  Avas  greatly 
enlarged,  the  right  lobe  being  much  the  larger,  while  the  isthmus  could 
be  traced  extending  below  its  usual  position,  as  a  band  about  1  inch 
in  vertical  measurement.  An  incision  about  3?  inches  long  being  made 
in  the  middle  line,  transverse  branches  of  the  anterior  jugular  vein 
being  tied  and  turned  aside,  the  isthmus  was  detached  by  the  finger 
and  director  from  the  front  of  the  trachea.  An  aneurism  needle  was 
then  made  to  perforate,  which  it  did  easily,  the  junction  of  the  isthmus 
with  each  lateral  lobe.  The  double  ligature  on  each  side  was  tied  as 
with  an  ovarian  pedicle,  and  the  isthmus  cut  away.  There  was  very 
little  haemorrhage.  The  trachea  was  very  much  compressed,  of  tri- 
angular shape,  with  the  apex  forwards,  and  each  lateral  surface  some- 
what concave.  Immediately  on  removal  of  the  isthmus  much  relief 
seemed  to  be  afforded  to  the  patient.  The  dyspnoea  quickly  ceased, 
and  when  the  patient  left,  in  less  than  two  months,  the  thyroid  could 
not  be  felt. 

Sir  W.  MacCormac*  alludes  to  three  other  cases  thus  treated  by  Mr. 
Sydney  Jones :  The  second  was  one  operated  on  for  exophthalmic 
goitre.  Here  great  benefit  followed  as  far  as  shrinking  of  the  lateral 
lobes  went,  but  the  patient  died  some  time  after  from  cerebral  mischief 
in  connection  with  the  general  disease.  In  the  two  remaining  cases, 
the  isthmus  not  being  so  well  marked,  the  lateral  lobes  were  so  approx- 
imated that  the  inner  portions  of  both  lateral  lobes  w^ere  removed, 
after  transfixion  with  a  double  ligature.  Great  relief  to  the  breathing 
and  swallowing,  and  shrinking  of  the  lateral  lobes  followed.  Mr.  S. 
Jones  considers  the  chief  object  of  this  operation  to  be  to  create  a  gap 
between  the  lateral  lobes,  a  deep  gutter  being  made  in  front  of  the 
trachea,  from  which  free  drainage  is  secured  during  the  process  of 
healing. 

I  have  followed  Mr.  Sydney  Jones  in  three  cases,  and  can  recom- 
mend this  operation  most  strongly.  All  three  cases  presented  enlarge- 
ment of  the  gland  generally,  in  addition  to  hypertrophy  of  the  isthmus. 
In  two  of  them  the  women  were  over  thirty,  with  marked  distress  in 
breathing  on  exertion  and  altered,  hoarse  voice.  The  mother  of  one 
of  the  patients  had  died,  aged  forty-four,  suddenly  with  dyspnoea 
accompanying  enlargement  of  the  thyroid.  Two  of  these  cases  have 
been  kept  under  observation  for  three,  and  one  and  a  half,  years 
respectively;  in  both  the  general  enlargement  has  subsided  steadily, 
with  entire  relief  of  symptoms.  The  third  case  showed  great  hyper- 
trophy of  the  whole  thyroid,  the   isthmus  consisting  of  a  bi-lobed 

*  Loc.  supra  cit. 


400  OPERATIONS    ON    THE    HEAD    AND    NECK. 

tumor  reaching  from  the  top  of  the  thyroid  cartilage  to  just  below  the 
manulnium.  This  patient  was  operated  on  more  recently,  but  the 
measurements  of  the  neck  showed  a  diminution  of  H  inch  within  a 
week  of  the  operation ;  this  decrease  went  on  advancing,  so  that  a 
fortnight  later  the  enlargement  of  the  right  lateral  lobe  had  entirely 
disappeared,  and  that  of  the  left  almost  equally  so.  The  marked 
tracheal  stridor,  breathlessness  on  any  exertion,  but  only  weakened 
voice,  were  accounted  for  by  finding  the  windpipe  in  this  case  an  ex- 
cellent instance  of  "  the  scabbard  trachea,"  this  tube  being  bluntly 
keel-like  in  front  with  concave  surfaces  from  the  strap-like  pressure 
of  the  enlarged  isthmus.  The  sides  of  the  thyroid  cartilage  showed, 
from  the  same  cause,  very  marked  concavities. 

I  would  most  strongly  urge  a  further  trial  of  this  operation  in  cases 
of  general  enlargement  of  the  gland,  especially  where  the  isthmus 
itself  is  enlarged.  This  can  be  raised  without  difficulty  with  a  steel 
director  or  blunt  dissector  from  the  trachea,  it  is  then  transfixed  at  its 
junction  with  the  lateral  lobes,  or  through  these  themselves,  with  a 
double  sulpho-chromicgut  ligature  (this  should  be  tested  beforehand). 
The  ligatures  l)eing  tied,  the  gland-tissue  is  snipped  through  between 
them,  the  isthmus  removed,  and  the  stumps  snipped  away  as  close  to 
the  remaining  ligatures  as  is  safe. 

Treatment  of  Enlarged  Thyroid  by  Ligature  of  the 
Thyroid  Arteries. — This  operation  was  performed  in  thirty -one 
known  cases,*  but  was  given  up,  (1)  from  deaths  due  to  wound-treat- 
ment of  former  days,  (2)  from  imperfect  results,  as  the  inferior  thyroid 
was  never  ligatured  at  the  same  time. 

Prof.  Wolfler,t  of  Vienna,  considering  that  the  various  methods  of 
treating  goitre  are  still  open  to  objections,  has  lately  advocated  a  trial 
of  the  above  method.  In  October,  1885,  he  made  use  of  it  in  a  patient 
aged  twenty-nine,  who  had  much  dyspnoea  from  a  rather  large  colloid 
thyroid,  the  right  half  being  somewhat  the  larger,  both  the  thyroid 
arteries  were  tied  on  this  side,  and  also  the  median  thyroid  vein.  The 
patient  was  discharged  nine  days  later,  the  dyspnoea  being  consider- 
ably relieved  and  gradually  subsiding  completely.  The  neck,  how- 
ever, did  not  diminish  in  size  at  the  same  rate.  A  week  after  the 
operation  the  median  circumference  had  diminished  1  cm.,  and  seven 
months  later  6  cm.,  when  the  right  side  of  the  goitre  had  shrank  to  one- 
half  its  former  size ;  the  left  side  had  diminished  somewhat.  Prof. 
Wolfler  considers  that  facts  indicate  (1)  that  neither  tying  of  both  su- 
perior thyroids  nor  of  the  inferior  alone,  can  be  considered  sufficient, 

*  Wolfler,  loc.  infra  cit. 

t   Wien.  Med.  WocL,  1886,  Nos.  29  and  30  ;  Ajin.  of  Surg.,  December,  1886,  p.  523. 


OPERATIONS   ON  THE  THYROID   GLAND.  401 

owing  to  the  free  anastomoses.  (2)  It  is  as  yet  questionable  whether  in 
large  one-sided  goitres  ligature  of  both  thyroids  on  that  side  ought 
to  be  accompanied  by  ligature  of  the  opposite  superior  thyroid.  (3) 
Ligature  of  all  four  arteries  could  hardly  lead  to  gangrene  of  the 
thyroid. 

It  would  perhaps  be  well  to  make  further  trial  of  this  operation  in 
cases  of  bronchoceles  requiring  an  operation  from  dyspnoea,  etc.,  and 
in  which  after  removal  of  one-half  the  diminution  in  the  opposite  half 
is  either  temporary  or  does  not  take  place  at  all.  I  think,  too,  that  in 
very  large  thyroids  this  method  might  be  combined  with  removal  of 
the  isthmus. 

The  arteries  may  be  found  by  the  following  methods.  It  is  right, 
however,  to  state  that  these  vessels  vary  so  much  in  situation  and  course, 
according  to  the  size  and  growth  of  the  bronchoceles  in  different  di- 
rections, that  any  dissections  for  finding  them  must  be  uncertain.  The 
chief  iDoints  to  bear  in  mind  are  the  upper  and  lower  parts  of  the  en- 
larged lobe:  the  superior  thyroid  artery  is  often  rendered  superficial 
by  the  upper  limit  of  the  tumor  raising  it  up.  Both  vessels  may  be 
enlarged  and  somewhat  softened,  and  thus  secondary  haemorrhage 
may  readily  occur  unless  the  wound  is  kept  sweet. 

Ligature  of  Superior  Thyroid  Artery. 

Relat[ons. — This  vessel,  the  first  branch  of  the  external  carotid, 
arises  just  above  the  bifurcation,  about  a  quarter  of  an  inch  below  the 
great  cornu  of  the  hyoid.  At  first  covered  only  by  thin  fasciae  and 
platysma,  it  ascends  slightly,  and  then  curves  downwards  with  a  tort- 
uous course,  covered  by  the  depressors  of  the  hyoid  bone  and  the 
sterno-thyroid. 

Operation. — The  patient's  head  being  suitably  raised,  and  turned 
to  the  o})posite  side^  an  incision,  about  two  inches  long,  is  made  along 
the  inner  border  of  the  sterno-mastoid,  with  its  centre  corresponding 
to  the  upper  border  of  the  thyroid  cartilage.  The  superficial  parts 
being  divided,  the  sterno-mastoid  and  the  large  vessels  are  drawn  out- 
wards, and  the  omo-hyoid  downwards  and  inwards,  or  else  tied  and 
divided.  The  artery  is  then  searched  for  with  the  point  of  a  steel 
director  in  the  hollow  between  the  larynx  and  the  carotid.  Some  en- 
larged veins,  belonging  to  the  superior  thyroid,  will  probably  require 
division  after  the  application  of  double  chromic  gut  ligatures. 

Ligature  of  Inferior  Thyroid  Artery. — This  operation  is  a 
good  deal  more  difficult,  owing  to  the  depth  of  the  vessel  and  its  more 
important  relations. 

Relations. — The  artery,  the  largest  branch  of  the  thyroid  axis, 
ascends  tortuously  inwards  behind  the  carotid  sheath,  the  middle 
cervical  ganglion  and  its  branches  lying  in  front  of  it.  Before  entering 
the  gland  it  lies  for  a  little  distance  in  relation  with  its  posterior  sur- 

26 


402  OPERATIONS    ON    THE    HEAD    AND    NECK. 

face,  and  in  this  part  of  its  course  the  recurrent  laryngeal  is  in  close 
contact  with  it.* 

Guide. — The  carotid  tubercle  of  Chassaignac,  or  the  transverse  pro- 
cess of  the  sixth  cervical  vertebra.  Sir  W.  MacCormac  gives  the  body 
of  the  fifth  cervical  vertebra,  opposite  to  which  the  artery  enters  the 
thyroid  gland.     The  common  carotid  is  also  a  guide. 

Operation. — An  incision,  3  inches  long,  being  made  along  the 
anterior  border  of  the  sterno-mastoid  coming  down  to  the  clavicle,  as 
if  for  ligature  of  the  carotid  low  down,  the  deep  fascia  is  opened  and 
the  sterno-mastoid  and  the  structures  in  the  carotid  sheath  drawn  out- 
wards. The  head  being  now  flexed  to  relax  the  parts,  the  carotid 
tubercle  is  felt  for,  and  the  artery  sought  for  below  it,  by  carefully 
working  here  with  a  director.  The  vessel  should  be  exposed  and  the 
ligature  a])plied  as  close  to  the  carotid  as  possible,  and  thus  at  some 
distance  from  the  thyroid  gland,  so  as  to  avoid  injury  to  the  recurrent 
laryngeal,  which,  as  above  stated,  crosses  over  the  trunk  or  ascends 
among  the  branches  of  the  inferior  thyroid.  The  neighborhood  of  other 
important  structures  must  be  remembered. f 

Treatment  of  Thyroid  Cysts  (Fig.  86). — These  are  sometimes 
of  much  importance  owing  to  their  size,  their  important  relations, 
and,  as  shown  by  Mr.  Glutton's  case  below,  by  their  occasional  vascu- 
larity. 

The  best  treatment  is  antiseptic  excision  whenever  this  is  practi- 
cable; with  much  larger  and  older  ones,  the  safest  and  the  one  most 
generally  applicable,  is  antiseptic  incision  and  drainage.  Injection 
with  iron  perchloride  has  given  some  good  results,  but  there  is  always 
the  risk  of  suppuration  and  cellulitis  in  a  very  dangerous  region 
owing  to  the  presence  of  the  larynx  above,  the  mediastinum  below, 
and  of  numerous  veins,  these  being  liable  to  puncture,  and  thus  to 
immediately  fatal  thrombosis,  or,  later  on,  to  septic  phlebitis. 

*  Sir  W.  MacConiiac  {Lig.  of  Arteries^,  p.  71)  says  that  the  nerveoften  passes  between 
the  terminal  branches  of  the  artery.  lie  reminds  the  operator  that  the  left  ai-tery  is 
in  close  contact  with  the  oesophagus,  and  that  the  thoracic  duct,  at  first  posterior,  arclies 
over  the  artery  on  this  side  to  enter  the  left  subclavian  vein. 

t  Wolfler  [he.  supra  cit.)  recommends  tying  tlie  artery  on  the  outer  side  of  the 
carotid  sheath,  between  the  two  heads  of  tlie  sterno-mastoid,  as  less  likely  to  damage 
the  im})ortant  structures  at  the  root  of  the  neck.  Tlie  incision  reaches  from  the  cricoid 
cartilage  to  the  clavicle,  the  lower  end  passing  between  the  inner  and  middle  thirds 
of  that  part  of  the  clavicle  which  extends  from  the  sulcus-deltoideo-pectoralis  to  the 
sternum.  The  superficial  parts  being  cut,  and  the  slit  between  the  two  heads  of  the 
sterno-mastoid  extended  upwards,  if  necessary,  the  omo-hyoid  is  seen  and  drawn  up- 
wards or  cut.  The  outer  border  of  the  internal  jugular  is  then  recognized,  and,  with 
the  carotid  sheath,  drawn  inwards,  while  the  scalenus  anticns  and  the  phrenic  nerve 
are  identified  with  the  director  and  drawn  outwards,  when  the  inferior  thyroid  will 
present  itself. 


OPERATIONS    ON    THE    THYROID    GLAND.  403 

Where  the  cyst  is  moderate  in  size  and  not  of  ver}'  long  duration, 
it  may  often  be  excised,  and  the  case  given  below  shows  that  this  may 
sometimes  be  practiced  where  the  cyst  is  huge  in  size  and  of  long 
duration.  But  in  the  majority  of  large  cysts  it  will  be  a  safer,  though 
more  tedious,  practice  to  incise  the  cyst  and  drain  it  with  careful 
aseptic  precautions,  a  method  which  is  applicable  to  nearly  all  cases, 
and  which  gives  the  surgeon  the  opportunity  of  exploring  the  cyst, 
especially  in  those  cases  where  it  is  covered  over  with  a  layer  of  gland- 
tissue,  or  where  it  has  complicated  contents. 

The  above  remarks  apply  to  single  cysts.  Mr.  Glutton  *  has  pointed 
out  that  where  there  are  many  cysts,  or  where  a  cyst  is  combined 
with  much  disease,  the  whole  half  of  the  thyroid  affected  had  better 
be  removed. 

The  method  of  incision  usually  involves  a  very  simple  operation. 
The  soft  parts  having  been  duly  cleansed,  an  incision  is  made  through 
them  down  to  the  cyst,  and  any  bleeding  points  secured.  The  cyst  is 
then  slit  open  and  its  interior  examined.  These  may  vary  consider- 
ably both  as  to  thickness  and  contents,  and  vascularity  of  lining 
membrane.  Thus  the  contents  may  be  a  serous,  mucoid,  gelatinous, 
or  grumous  material,  or  coagulated  blood-clot.  The  amount  of  vascu- 
larity is  of  twofold  importance :  if  of  very  long  standing  the  cyst-wall 
may  be  so  fibrous  and  vascular  that  sloughing  of  it  may  readily  take 
place,  especially  if  the  wound  becomes  septic.  On  the  other  hand,  it 
may  be  extremely  vascular,  in  which  case  such  abundant  haemorrhage 
will  take  place  as  to  leave  no  time  for  suturing,  and  require  imme- 
diate plugging  with  aseptic  gauze. t 

Knowing  how  tedious  these  cases  are  in  granulating  from  the 
bottom  and  becoming  completely  obliterated,  I  prefer  to  suture  the 
cut  edge  of  the  cyst  to  the  surrounding  margin  of  the  skin,  and  then, 
with  a  sharp  spoon,  to  scrape  over  the  lining  membrane,  thus  pro- 
moting the  closing  of  the  cavity  from  the  bottom.  A  drainage-tube 
is  then  inserted,  the  cavity  plugged  with  strips  of  gauze,  and  the 
dressings  applied.  Mr.  Glutton,  however,  considers  that  sutures  are 
not  necessary  if  the  tissues  between  the  cyst  and  the  skin  have  not 
been  much  disturbed ;  if  the  contrary  has  happened,  sutures  may  be 
harmful,  as  they  would  tend  to  prevent  escape  of  discharges  from  the 
meshes  of  the  deep  cervical  fascia. 

I  would  draw  attention,  again,  to  the  very  important  fact  that  in 
these,  as  in  all  other  thyroid  cases  (and  in  many  others),  where  pri- 
mary union  is  not  secured,  silk  ligatures,  if  many  of  these  have  been 
used,  may  continue  to  come  away  for  a  very  prolonged  jjeriod.     The 

*  St.  Thomas's  Hosp.  Reports,  vol.  xvi.  p.  173. 

f  As  happened  in  a  oase  of  Mr.  Glutton's  {loc.  supra  cit.). 


404 


OPERATIONS    ON   THE    HEAD    AND    NECK. 


cyst  quickly  falls  in  and  puckers  together,  but  a  sinus  is  liable  to 
persist  through  which  ligatures  are  long  discharged.  Thus,  in  one  of 
Mr.  Glutton's  cases  a  sinus  persisted  for  two  years,  and  then  quickly 
closed ;  in  another  the  patient  was  still  wearing  a  drainage-tube,  a 
year  after  the  operation.  And  in  the  case  of  mine  now  mentioned,  it 
was  not  till  nine  months  after  the  operation  that  the  last  ligature 
came  away,  and  the  wound  soundly  closed.* 

As  bearing  on  the  treatment  of  thyroid  cysts  by  excision,  and  as  a 
good  example  of  one  of  the  complications  which  may  follow  opera- 

FiG.  85. 


tions  on  the  thyroid  gland,  I  may  now  mention  the  following  case 
(Fig.  85): 

A  gentleman,  aged  fifty-five,  was  sent  to  me,  towards  the  close  of 
1885,  by  Mr.  Cooper  Forster,  with  a  right-sided  thyroid  cyst,  almost 


*  In  my  case  plaited-twist  silk  (Turner's)  was  used.  This  is  so  closely  interwoven 
as  to  resist  changes  in  the  tissues  and  absorption  most  obstinately.  I  have  been  much 
disappointed  at  the  way  in  which  it  keeps  a  sinus  persistent  and  comes  away  long 
after  such  operations  as  radical  cure  of  hernia,  nephroraphy,  and  nephrectomy.  For 
buried  sutures  or  ligatures  ordinary  silk  of  appropriate  thickness  is  much  to  be  pre- 
ferred, being  equally  safe  and  with  a  much  more  open  texture. 


OPERATIONS    ON    THE   THYROID    GLAND.  405 

colossal  in  size,  and  reaching  from  the  ear  to  below  the  clavicle,  and 
outwards,  into  the  posterior  triangle.  The  trachea  was"  under  the 
edge  of  the  left  sterno-mastoid.  The  swelling  was  first  noticed  twenty- 
six  years  before,  being  then  about  the  size  of  a  hazel-nut.  About 
nineteen  years  ago,  owing  to  some  dyspnoea,  the  swelling  was  tapped 
by  Mr.  Forster;  gradually  refilling  and  increasing  in  size  it  was 
tapped  by  myself  in  1885,  the  fluid  being  thick  with  material  resem- 
bling Parmesan  cheese.  As  the  cyst  quickly  refilled,  I  proposed  free 
incision  and  drainage,  and  sought  first  the  opinion  of  my  colleague, 
Mr.  Durham.  As  in  spite  of  twenty  six  years'  history  the  cyst  had  a 
certain  distinct,  though  limited,  amount  of  mobility,  Mr.  Durham 
advised  extirpation  in  preference  to  excision.  This  counsel  I  accord- 
ingly followed.  Ether  was  taken  very  badly,  especially  at  first.  An 
incision  being  made  from  the  angle  of  the  jaw  to  the  right  sterno- 
clavicular articulation,  the  sterno-mastoid  was  found  spread  out  over 
the  cyst  and  adherent  to  it,  perhaps  from  the  previous  tappings.  As 
the  patient  was  breathing  very  badly,  no  time  was  spent  in  separating 
the  muscle,  but  the  cyst  was  reached  by  cutting  away  the  adherent 
part.  The  sujDerior  thyroids  being  found  and  tied,  the  cyst  was  turned 
downwards  out  of  its  bed,  partly  with  the  finger,  partly  with  a  blunt 
dissector;  a  vessel  in  the  position  of  the  middle  thyroid  vein  was 
found,  and  a  small  vessel  below  where  the  inferior  thyroid  was  ex- 
pected. The  chief  attachment  of  the  cyst  was  in  the  middle  line, 
where  it  was  connected  with  the  isthmus  (not  itself  enlarged)  by  a 
fairly  fleshy  pedicle.  This  was  separated  from  the  trachea  and  tied 
in  three  pieces,  partly  with  the  aid  of  a  steel  director,  partly  with 
an  aneurism  needle.  About  fourteen  carbolized  silk  ligatures  were 
used,  and  strict  antiseptic  precautions  were  taken  throughout,  includ- 
ing the  use  of  the  s^Dray.  An  enormous  cavity  remained  when  the 
cyst  was  shelled  out,  exposing  the  common  carotid  and  its  bifurcation, 
the  larynx  and  trachea,  but  though  a  strong  light  was  thrown  into 
the  bottom  with  a  mirror,  nothing  could  be  seen  of  the  oesophagus  or 
recurrent  laryngeal.  Special  care  was  taken  to  verify  this,  as  towards 
the  close  of  the  operation  (which  lasted  twenty-five  minutes)  there 
was  some  vomiting  of  coffee-ground  stuff,  streaked  here  and  there 
with  brightish  blood. 

No  dyspnoea  and  no  lividity  had  been  noticed  during  the  operation, 
beyond  the  difficulty  which  had  from  the  first  accompanied  the 
anaesthetic.  As  the  effects  of  the  ether  subsided,  a  peculiar  stridor 
was  found  to  accompany  the  breathing,  being  much  more  marked  in 
inspiration.  The  voice  was  not  affected,  beyond  being  weak,  and 
there  was  no  lividity.  The  stridor,  but  without  marked  dyspnoea, 
went  on  increasing  for  about  two  hours,  the  patient  being  much 
alarmed  from  dreaded  "  choking."     Though  he  vowed  that  he  could 


406  OPERATIONS    OX    THE    HEAD    AND    NECK. 

not  swallow  owing  to  the  above  alarm  and  from  the  feeling  of  soreness 
"  like  a  bone  in  the  throat,"  he  was  persuaded  to  take  a  dose  of  potas- 
sium bromide,  and  passed  a  fairly  good  night.  The  next  day  was  a 
comfortable  one,  and  the  breathing,  which  was  twenty  in  the  minute, 
was  much  easier,  and  perfectly  so  while  the  patient  slept.  The  next 
two  days  were  very  anxious  ones,  the  stridor  returning,  with  great 
restlessness  and  distress,  on  account  of  paroxysmal  attacks  of  dyspnoea. 
Accompanying  these  a  condition  of  quiet  delirium  set  in.  The  respi- 
rations ran  up  to  40,  the  pulse  to  140,  while  the  temperature  remained 
99°.  The  wound  was  now,  and  throughout,  perfectly  sweet.  As  there 
was  some  carboluria  (without  albumen),  the  drainage-tubes  were 
syringed  out  with  boracic  acid  and  iodoform  gauze  dressings  applied 
as  before. 

The  pulse  was  of  grave  omen,  about  every  ten  or  twelve  beats  drop- 
ping, fluttering,  and  then,  as  it  were,  staggering  on,  to  intermit  again 
in  another  ten  beats.  This,  Dr.  Goodhart  thought,  might  be  due  to 
some  chloral  that  had  been  given  at  night. 

The  diagnosis  at  this  time  was  doubtful — whether  the  case  was  one 
of  injury  to  the  recurrent  laryngeal  or  one  of  oedema  glottidis.  Mr. 
Durham,  who  inclined  to  the  latter  view,  advised  the  use  of  warm, 
moist,  boracic  acid  lint-dressings,  and  inhalations  of  steam  and  tere- 
bene. 

The  breathing  gradually  became  less  laborious  and  noisy,  and  the 
power  of  swallowing  quickly  returned.  Recovery  was  retarded  by  a 
succession  of  fogs  and  some  localized  pneumonia,  which,  giving 
anxiety  at  first,  entirely  cleared  up  under  Dr.  Goodhart's  hands. 
When  the  patient  left  town,  six  weeks  after  the  operation,  there  was 
no  difficulty  in  swallowing,  the  stridor  was  only  noticed  on  deep  res- 
piration, or  during  quick  or  prolonged  talking.  The  wound  was  now 
represented  by  a  sinus  at  the  lower  end  ;  all  the  rest  was  well  healed. 
Ligatures  continued  to  come  away  for  nine  months,  when  the  wound 
healed  at  once.  There  is  now,  two  years  after  the  operation,  still  a 
very  little  stridor  on  deep  breathing  or  rapid  talking,  and  the  voice  is 
still  a  little  husky,  but  the  patient  is  able  to  follow  his  employment 
actively  and  to  get  quickly  over  hilly  ground.* 

While  the  diagnosis  here  remains  obscure,t  I  am  of  ojDinion  that, 

*  A  year  after  the  operation  he  wrote  thus:  "I  have  not  been  so  strong  and  active 
for  many  years.  The  other  day  I  went  in  the  morning  to  London,  to  the  Academy, 
Grosvenor,  '  Alice  in  Wonderland,'  Fitzroy  House,  then  to  a  council-meeting  of  the 
Photographic  Society,  and  home.  There  was  a  damp  fog  all  day,  and  I  am  not  the 
worse  for  it." 

f  Owing  to  a  projection  of  the  incisor  teeth,  and  a  life-long  difficulty  in  opening  the 
mouth  widely,  it  was  found  impossible — Mr.  Durham  and  Dr.  Goodheart  also  trying 
— to  get  a  view  of  this  patient's  larynx. 


REMOVAL  OF  GROWTHS  IN  THE  NECK.  407 

with  the  bloody  vomit  in  the  course  of  the  operation,  the  great  dys- 
phagia afterwards,  although  the  huge  cyst  turned  out  so  quickly,  some 
slight  injury  was  inflicted  on  the  oesophagus,  with  stretching  or  im- 
bedding in  inflammatory  effusion  of  the  right  recurrent  laryngeal. 
Whether  this  is  right  or  not,  I  think,  with  all  proper  deference  to  Mr. 
Durham's  opinion,  that  this  case  shows  that,  in  cases  of  thyroid  cysts, 
when  large  or  of  long  standing,  incision,  with  antiseptic  precautions, 
is  preferable  to  excision. 


CHAPTER   XIV. 


REMOVAL  OF  LARGE  DEEP-SEATED  GROWTHS 
IN  THE  NECK. 

Before  deciding  to  undertake  the  removal  of  one  of  these,  the  sur- 
geon should  consider  carefully  the  following  points  : 

A.  The  nature  and  surroundings  of  the  growth. 

B.  His  operative  skill  in  these  cases,  and  his  knowledge 

of  anatomy. 

C.  His  experience  in  antiseptic  surgery  and  in  keeping  a 

large  wound  aseptic. 

The  chief  growths  which  call  for  a  decision  are  the  following  :  The 
rarely  met  with  more  innocent  ones — e.g.,  the  enchondroma  of  Prof. 
Spence,*  the  fibrous  tumor  of  Mr.  Butcher,t  glandular  tumors,  in- 
cluding the  more  simple  strumous  lymphomata,  when  they  do  not 
yield  to  other  treatment ;  sarcomata,  very  likely  cystic,  originating  in 
the  neck  apart  from  the  cervical  glands ;  sarcomata  of  the  glands ; 
carcinomata  of  the  glands,  secondary  to  epithelioma  of  the  tongue, 
lip,  etc. 

Of  the  three  points  above  mentioned,  it  will  only  be  needful  to  con- 
sider separately  the  first;  the  importance  of  the  two  others  will  be 
sufficiently  shown  in  the  remarks  on  the  operation  and  after-treat- 
ment. 

A.  The  Nature  and  Surroundings  of  the  Growth.  J— In  ex- 


*  Growths  of  the  tonsil  are  considered  at  p.  340.     Bronchocele  at  p.  385. 

f  This  case,  in  which  the  growth  weighed  over  7  lbs.,  is  related  in  the  Dub.  Journ. 
J/ed.  iSci.,  November,  1863.  Mr.  Butcher's  case  will  be  found  amongst  his  Operative 
Surgery  Essays,  p.  809.  The  reader  should  also  consult  Mr.  Holmes's  remarks  on 
these. cases  (Syst.  of  Surg,  vol.  viii.  p.  886),  a  paper  by  Mr.  Barker  {Lancet,  1886, 
vol.  i.  p.  194),  and  one  by  Mr.  Jessett,  illustrated  by  some  admirable  photographs 
{Brit.  Med.  Journ.,  1886,  vol.  ii.  p.  712). 

X  Mr.  Holmes  {loc.  supra  cit.)  quotes  Langenbeck  {Arch.f.  Klin.  Chir.,  Bd.  1,  Hft. 
4,  s.  14)  as  pointing  out  that,  in  tumors  which  involve  the  sheath  of  t!ie  vessels,  en- 


408  OPERATIONS    ON    THE    HEAD    AND    NECK. 

amining  into  these,  careful  attention  should  be  paid  to  the  following: 
Duration.  Rate  of  increase.  Amount  of  fixity.  Whether  early  estab- 
lished, and  how  far  absolute.  This  point  is  of  the  utmost  importance. 
The  gravest  cause  of  fixity  is,  of  course,  a  growth  with  a  wide  base,  or 
numerous  root-like  processes  extending  into  important  parts.  The 
fixity  should  be  tested  by  seeing  how  far  the  finger-tips  can  be  insinu- 
ated beneath  the  growth,  how  far  it  can  be  lifted  up,  and  the  amount 
of  its  connection  to  parts  such  as  the  jaw  and  larynx,  the  head  being 
steadied  by  an  assistant  while  the  growth  is  lifted  up  and  its  deep 
processes  put  on  the  stretch  as  much  as  possible.  The  outline.  Is  this 
well  marked  or  indistinct,  and,  if  the  latter,  is  it  in  dangerous  regions 
such  as  the.  parotid,  the  zygomatic,  and  other  fossae,  that  the  growth 
is  lost?*  Its  relation  to  imiwrtant  structures,  and  the  degree  to  which  it 
blends  with  them.  Thus,  any  evidence  of  pressure  on  vessels  and  nerves, 
trachea  and  pharynx,  etc.,  should  be  carefully  looked  for — e.g.,  weak- 
ness of  temporal  pulse,  engorgement  of  veins  above,  alteration  of 
pupil,  numbness  of  upper  limb,  dyspnoea,  or  dysphagia.  Does  the 
growth  dip  near  or  into  the  thorax?  How  far  under  the  sterno-mas- 
toid  does  it  go?  Are  the  glands  enlarged  as  well ?  Is  the  skin  in- 
volved ?  This  last  point,  together  with  fixity,  indistinctness  of  outline, 
rapid  growth,  softness  and  fusion  with  surrounding  parts,  are  of  chief 
importance,  and,  if  coexisting  to  any  extent,  will  usually  put  any 
operation  out  of  the  question. 

But  even  when  the  surgeon  is  doubtful,  or  more  than  doubtful,  as 
to  the  advisability  of  meddling  with  one  of  these  growths,  no  one 
would  blame  him  for  making  an  attempt  under  the  following  circum- 
stances, even  if  it  end  in  failure : 

When  the  patient's  life  is  rendered  worthless  by  the  present  wretch- 
edness and  approaching  dangers  of  the  growth,  especially  if  he  be 
young,  as  in  the  following  vivid  words  of  Mr.  Butcher  :* 

"  Though  the  boy  did  not  suffer  pain,  yet  his  life  was  rendered  very 
miserable  ....  the  weight  ever  tending  to  depress  the  head,  occa- 
sioning persistent  fatigue  and  even  pain  in  the  muscles  of  the  neck, 
and  so  compelling  the  patient  often  to  adopt  the  recumbent  position, 
the  bulk  thrusting  up  the  head,  embarrassing  every  movement,  almost 
preventing  any  change  of  position ;  the  pressure  impeding  respiration, 
often  obstructing  it  during  sleep  so  as  momentarily  to  threaten  suffo- 
cation, making  the  patient  start  from  his  bed  in  terror  and  alarm, 

o-orgenient  of  the  veins  of  the  face  is  rarely  absent.    In  one  case  he  observed  this  venous 
engorgement  to  be  on  the  opposite  side  of  the  tumor  only.     This  he  attributed  to  the 
fact  that  the  tumor  compressed  the  carotid  artery  as  well  as  the  jugular  vein,  as  proved 
by  the  weakness  of  the  temporal  pulse. 
*  Loc.  supra  cit.,  p.  871. 


REMOVAL    OF   GROAVTHS    IN    THE    NECK.  409 

unrelenting  or  enforcing  one  attitude  during  sleep,  with  difficulty  in 
deglutition,  excejat  under  extreme  watchfulness  in  adopting  position." 
So,  too,  in  some  cases  of  cancerous  glands,  associated  with  epithe- 
lioma— e.g.,  on  the  tongue — the  surgeon  may  justifiably  perform  an 
extensive  operation,  such  as  Kocher's  (p.  335),  in  the  hoj^e  of  removing 
both  the  primary  and  secondary  epithelioma,  or  after  a  successful 
removal  of  the  tongue  operate  on  the  infected  glands  widely  and 
deeply  to  give  the  patient  another  prolongation  of  life.  In  such  cases 
it  should  be  the  patient  who  urges  operation  after  all  the  risks  have 
been  placed  before  him. 

Main  Points  in  the  Operation  itself. 

i.  Free  Exposure  of  the  Growth. — The  incisions  should  be 
sufficient,  the  flaps  turned  back  V,  f,  or  X  in  shape.  Thus,  if  the 
growth  be  in  the  anterior  triangle,  not  encroaching  on  the  posterior,  a 
V-shaped  flap  with  the  base  upwards,  one  limb  along  the  sterno-mas- 
toid  and  the  apex  above  the  sternum,  may  be  employed ;  or  one  V  in 
shape,  the  long  limb  inside  the  above-mentioned  muscle,  and  one  at 
right  angles  to  it  under  the  jaw.  If  the  growth  invade  both  triangles, 
and  if  it  will  be  necessary  to  divide  the  sterno-mastoid,  an  incision 
obliquely  across  both  triangles,  and  over  the  muscle,  from  mastoid  pro- 
cess to  sternum,  and  then  a  second  to  make  it  conical,  will  be  the  best. 
It  is  always  to  be  remembered  that  inadequate  exposure  of  the  tumor 
will  lead  to  groping  in  the  dark,  bruising  of  the  soft  parts,  and  injury 
to  important  structures. 

ii.  Deeper  Dissection. — In  this  attention  must  be  paid  to — 

(a)  Working  as  much  as  possible  with  a  blunt  dissector,  a  steel  di- 
rector, or  the  finger,  using  the  scalpel  and  blunt-pointed  scissors  as 
little  as  possible,  and  keeping  them  turned  towards  the  growth.  The 
dissection  should  be  begun,  as  a  rule,  where  the  growth  is  most  free, 
and  where  its  relations  are  not  important. 

(i?)  Tying  with  chromic  gut  or  carbolized  silk*  ever}'  vessel  before 
it  is  divided,  not  only  to  minimize  the  loss  of  blood,  but  also  to  avoid 
the  risk  of  air  entering  the  veins,  especially  low  down  in  the  neck. 

(y)  Structures,  hitherto  thought  too  important,  may  be  divided,  if 
really  needful.  Thus,  not  only  the  sterno-hyoid  and  omo-hyoid 
should  be  divided,  but  the  sterno-mastoid  also.  Of  the  structures  in 
the  carotid  sheath,  the  internal  jugular  is,  as  pointed  out  by  Mr. 
Holmes,  the  most  likely  to  be  implicated.  It  may  be  divided  without 
hesitation  after  it  is  secured  with  two  catgut  ligatures.f 

In  the  autumn  of  1877,  while  operating  for  Mr.  Cooper  Forster,  I 

*  See  the  remarks  on  carbolized  silk,  p.  404. 

t  Mr.  Barker  (Lancet,  1886,  vol.  i.  p.  194)  records  a  case,  probably  a  cystic  sarcoma, 
in  which  li  inch  of  this  vein  was  involved  in  the  growth  and  removed.  The  case  did 
well. 


410  OPERATIONS   ON    THE    HEAD    AND    NECK. 

tore  through  the  internal  jugular  vein  in  removing  some  epithelioma- 
tous  glands :  the  haemorrhage  was  for  a  moment  very  profuse,  but 
yielded  to  sponge-pressure.  Catgut  ligatures  were  applied  to  the  two 
halves  of  the  vein,  and  the  patient  recovered.  In  a  similar  operation 
the  lingual  vein  was  separated  so  close  to  the  internal  jugular  as  to 
leave  little  more  than  a  rounded  opening.  In  preference  to  tying  the 
vein  above  and  below  I  left  a  pair  of  Spencer  Wells's  forceps  on  for 
three  days.  Recovery  took  place.  The  common  carotid  and  even  the 
vagus  have  been  divided,  and  without  a  fatal  result. 

M.  Sabat*  successfully  extirpated  a  tumor  extending  from  the 
mastoid  process  to  the  clavicle,  and  lying  altogether  beneath  the 
sterno-mastoid,  which  was  divided  in  order  to  expose  it.  The  carotid 
and  internal  jugular  had  to  be  tied,  and  the  pneumogastric  nerve  was 
divided. 

In  a  case  of  Dr.  Gibson  (Amer.  Jour.  Med.  Sci.^  vol.  xiii.  p.  305),  a 
tumor  was  successfully  removed  after  the  carotid  and  internal  jugular 
had  been  tied  and  divided.f  The  descendens  noni  was  cut,  but  the 
vagus  was  dissected  out  of  the  mass.  The  patient  recovered  from  the 
operation,  but  the  growth  recurred,  though  it  was  enveloped  in  a  very 
firm  and  distinct  capsule. 

In  a  deep  dissection  the  presence  of  some  other  structures  must  be 
remembered. I 

Mr.  Godlee  (Clin.  Soc.Trans.,  vol.  xix.  p.  321)  showed  a  child  in  whom, 
during  the  removal  of  a  deep-seated  growth,  the  nature  of  which  was 
doubtful  and  which  was  pressing  upon  the  pharynx,  the  cervical  sym- 
pathetic had  been  wounded.  The  only  results  were,  that  the  pujnl  on 
that  side  was  smaller  but  not  stationary,  and  that  the  ocular  slit  was 
also  smaller. 

Mr.  Barker,  in  the  case  of  cystic  sarcoma  to  which  reference  has  been 
already  made,  removed  part  of  the  scalenus  anticus  to  which  the 
growth  was  adherent.     The  phrenic  was  not  interfered  with. 

In  1870  I  saw  the  thoracic  duct  opened  in  an  operation  for  the  re- 
moval of  enlarged  glands  on  the  left  side.  Chyle  escaped  deep  down 
in  the  wound,  and  the  case  soon  ended  fatally. 

(5)  If  possible,  the  growth  capsule,  which  is  often  soft  and  delicate, 
*      ^ ^ , 

*  This  and  the  next  case  are  given  by  Mr.  Holmes  Hoc.  supra  cit.,  p.  887). 

t  Mr.  Jessett  {Brit.  Med.  Journ.,  1886,  vol.  ii.  p.  713)  mentions  a  case  in  which  he 
divided  the  common  carotid  and  internal  jugular  vein  in  removing  epitheliomatous 
glands  from  the  neck.  The  man  recovered,  and  lived  in  comparative  comfort  for  nine 
months,  death  taking  place  from  a  local  recurrence. 

J  In  the  posterior  triangle  growths  springing  from  thelower  vertebra  or  the  first  rib 
may  involve  the  cords  of  the  brachial  plexus,  causing  much  pain  and  requiring  very 
tedious  dissection  for  their  removal.  See  a  case  brought  before  the  Medico-Chirurgical 
Society,  January  12,  1886,  by  Dr.  Bruce  and  Mr.  Bellamy. 


CESOPHAGOTOMY.  411 

must  not  be  ruptured.  On  examining  the  growth  after  removal,  the 
capsule  should  not  only  be  entire,  but  any  process  should  be  blunt  and 
rounded,  not  soft  and  ragged,  as  if  torn  away  from  parts  left  behind. 

If  the  surgeon  feel  doubtful  as  to  any  portion  being  left,  as  in  the 
fossffi,  about  the  base  of  the  skull,  he  should  use  a  sharp  spoon  and 
Paquelin's  cautery,  or  pack  in  lint  with  a  paste  of  equal  parts  of  zinc 
chloride- and  flour. 

(e)  Throughout  the  operations,  which  may  necessarily  be  prolonged 
and  attended  with  loss  of  blood,  and  in  which  important  parts  may 
be  disturbed  and  pulled  upon,  the  surgeon  should  keep  himself  in- 
formed as  to  the  efiects  of  the  anaesthetic. 

iii.  Closure  of  the  Wound  and  Application  of  Dressings. 
— After  completely  removing  the  growth  and  any  outlying  glands,  drain- 
age is  provided  from  the  extremities  of  the  resulting  cavities,  and  in  ac- 
cordance with  the  position  which  the  patient  will  occuj^y.  Tubes  of 
sufficient  size  being  in  position,  the  wound  is  brought  together  with 
wire  or  carbolized  silk,  or  wire  and  horsehair  sutures ;  dressings  of  sal 
alembroth  or  iodoform  gauze  are  then  adjusted,  pressure  being  ap- 
plied, wherever  discharge  might  collect,  with  aseptic  pads  or  sponges. 
Firm,  even  bandaging  is  then  made  use  of  to  distribute  the  discharge 
equally  throughout  the  dressings  and  to  keep  the  parts  at  rest.  Owing 
to  the  mobility  of  the  neck,  and  the  impossibility  of  applying  firm 
pressure  over  the  trachea,  it  is  always  well  to  carry  the  bandages, 
below,  across  the  axilhie,  and,  above,  on  to  the  face  and  forehead,  and  to 
have  them  stitched  in  several  places.  Unless  it  is  absolutely  indicated, 
the  wounds  should  not  be  looked  at  for  five  or  six  days. 


CHAPTER  XV. 

OPERATIONS   ON    THE    OESOPHAGUS. 

ffiSOPHAGOTOMY.    (ESOPHAGOSTOMY. 
CE3OPHAGE0TOMY. 

CESOPHAGOTOMY. 

Indications. — This  is  required  for  such  foreign  bodies  as  have 
resisted  careful,  justifiable  attempts  at  extraction,  bodies  which  are 
certain,  if  left,  to  lead  to  grave  results — e.g.,  haemorrhage,  sloughing, 
deep  cervical  suppuration,  etc. 

Amongst  such  bodies  are — 

Tooth-plates ;  bones ;  pins  swallowed  in  soft  food ;  coins. 

It  will  be  wise  to  proceed  to  an  early  operation,  and  thus  avoid  the 


412  OPERATIONS   ON   THE    HEAD    AND    NECK. 

risks  of  a  fatal  result  from  those  conditions  given  at  p.  416.  In  making 
up  his  mind  to  submit  his  patient  to  an  operation,  the  surgeon  must 
weigh  the  size  and  character  of  the  body,  the  time  it  has  been  swal- 
lowed, the  urgency  of  the  symptoms— e.j/.,  dysphagia,  dyspnoea  from 
pressure  on  the  larynx,  emphysema,*  oedema,  etc.,  and  whether  the 
attempts  already  made  at  extraction  are  all  that  are  justifiable,  and 
whether  the  instruments  at  hand  have  been  appropriate. 

Operation. — The  head  being  somewhat  extended  and  turned  to 
the  right  t  side,  the  neck  shaved  (if  needful),  the  surgeon  makes 
an  incision  3  inches  long  from  just  above  the  thyroid  cartilage  to 
within  i  inch  of  the  sterno-clavicular  joint,J  a  little  in  front  of  the 
anterior  border  of  the  sterno-mastoid.  Skin  and  fascia  being  divided,§ 
the  cellular  tissue  in  front  of  the  above-mentioned  muscle  is  opened 
up  with  a  director,  and  the  pulsation  of  the  artery  and  the  bodies  of 
the  cervical  vertebra?,  fifth  and  sixth,  felt  for.  The  omo-hyoid  may  be 
drawn  down,  but  it  is  best  to  divide  this  muscle  between  chromic-gut 
ligatures,  and,  if  it  be  needful  to  seek  for  the  body  low  down  in  the 
neck,  the  sterno-hyoids  and  sterno-thyroids  also.  The  sterno-mastoid 
and  large  vessels  are  now  drawn  outwards,  and  the  trachea  ||  inwards, 
with  retractors,  the  thyroid  gland  probably  showing  plainer  on  the 
inner  side,  and  the  internal  jugular,  if  dilated,  on  the  outer.  The 
presence  of  the  inferior  thyroid  behind  the  carotid  sheath,  and  that  of 
the  recurrent  laryngeal  running  up  in  the  groove  between  the  trachea 
and  oesophagus,  must  be  remembered.  Throughout  these  steps  of  the 
operation  the  bleeding  must  be  most  carefully  arrested,  and  the  deeper 
part  of  the  wound,  with  the  important  structures  around  it,  kept 
quite  dry. 

*  In  a  case  where  emphysema  already  exists  with  an  impacted  foreign  body,  it  will 
be  wiser  to  open  the  oesophagus  at  once,  and  not  make  attempts  at  extraction.  Dr. 
Church  (St.  Barthol.  Hosp.  Reports,  vol.  xix.  p.  55)  gives  a  case  in  which  swelling  of  the 
neck  began  three  hours  after  the  tooth-plate  had  been  swallowed.  The  next  day,  after 
several  attempts  with  a  horsehair  probang,  the  plate,  which  lay  midway  between  the 
larynx  and  the  sternum,  was  brought  up  into  the  reach  of  forceps  and  extracted  by  Mr. 
Savory.  Death  took  place  two  days  later,  there  being  perforation  of  the  end  of  the 
pharynx,  with  suppuration  in  the  neck,  mediastina,  and  left  pleura. 

f  The  left  side  is  preferable,  as  the  oesophagus  lies  more  to  this  side,  and  as  opera- 
ting on  the  left  side  allows  of  freer  movement  of  the  right  hand,  while  the  left  is  at 
liberty  to  move  the  larynx,  etc. 

j  If  the  neck  is  very  stout,  or  if  the  parts  are  swollen,  etc.,  the  incision  may  be  from 
just  below  the  angle  of  the  jaw  to  close  to  the  sternum. 

I  The  anterior  jugular  vein  may  give  trouble,  and  should  be  drawn  aside,  or  divided 
between  two  catgut  ligatures. 

II  The  larynx  should  not  only  be  drawn  to  the  right,  but  tilted  over  to  this  side  also, 
as  this  brings  up  the  oesophagus. 


CESOPHAGOTOMY.  413 

If  the  foreign  body  cannot  be  felt*  projecting  in  the  oesophagus — 
e.g.,  behind  the  cricoid — the  month  should  be  opened  with  a  gag,  and 
a  bougie  or  probang  passed  as  the  flaccid  tube-walls  are  naturally  in 
contact.  When  the  oesophagus  lies  unusually  deep,  following  round 
the  thyroid  or  cricoid  cartilage  with  the  finger  will  find  it. 

When  the  site  of  the  foreign  body  has  been  made  out,  or  when, 
failing  this,  it  is  decided  to  open  the  oesophagus  low  down  and  to  pass 
probes,  etc.,  the  oesophagus  must  be  opened  with  a  clean  cut,  as  far 
back  as  possible,  so  as  to  avoid  the  recurrent  laryngeal  filaments.f 

When  the  tube  has  been  opened,  and  any  bleeding  from  its  walls 
arrested,  the  opening  is  dilated  by  dressing  forceps,  by  a  probe-pointed 
bistoury,  or  by  curved  forceps  passed  from  the  mouth  and  expanded 
in  the  wound.  Even  after  a  free  opening  has  been  made  it  may  be 
impossible  to  dislodge  the  body,  if  this,  a  tooth-plate,  has  projecting 
clips,  or  if  it  is  tightly  embraced  by  the  contraction  of  the  oesophageal 
fibres.  In  such  a  case  the  body  should  be  (if  a  tooth-plate)  divided 
with  bone-forceps  and  removed  in  two  portions,  care  being  taken  to 
keep  hold  of  each  portion  with  forceps  (Lawson,  Clin.  Soc.  Trans., 
xviii.  292). 

If,  after  exposing  the  (Psophagus,  the  body  cannot  be  felt,  which 
will  rarely  happen,  metallic  probes  or  soft  bougies  should  be  passed 
through  the  wound  in  the  oesophagus,  and  the  lower  cervical,  and  the 
upper  thoracic,  portions  of  this  tube  carefully  explored.  The  ques- 
tion may  now  be  considered  :  How  far  down  from  the  oesophagus  can 
a  body  be  extracted  ?  The  most  accessible  part  is  no  doubt  its  junc- 
tion with  the  pharynx,  opposite  to  the  cricoid  cartilage,  and  the  first 
two  inches  below  this  point.  Mr.  Cock  {loc.  supra  cit.)  writes:  "It 
might  even  be  possible  to  extract  a  foreign  body  from  the  early  tho- 
racic portion,  provided  it  could  be  reached  with  the  finger,  and  thus 
brought  under  the  influence  of  a  pair  of  curved  forceps. "J 

*  It  must  always  be  remembered  that  the  precise  site  of  the  foreign  body  is  not 
always  marked  by  any  external  swelling  or  resistance,  nor  by  accurately  referred  pain  ; 
furthermore,  bougies  occasionally  give  very  slight  indications  of  the  presence  of  bodies 
(even  rough  ones)  in  the  oesophagus  or  pharynx. 

t  Mr.  Cock  {Guy's  Hasp.  Reports,  1868,  p.  3)  draws  attention  to  this  point.  Both  his 
patients  were  in  the  habit  of  singing;  in  the  first  {Ibid.,  18o8,  p.  229)  case  a  fine  tenor 
voice  was  replaced  by  a  bass;  in  the  second,  in  which  the  cesophagns  was  opened 
farther  back,  the  voice  did  not  suffer. 

X  The  proximity  of  important  parts  to  the  thoracic  portion  of  the  ojsophagus  is  well 
known.  Thus,  in  Path.  Soc.  Trans.,  vol  xix.  p.  219,  is  recorded  the  case  of  a  man  who 
swallowed  a  bone  which  lodged  in  the  oesophagus  opposite  to  the  arch  of  the  aorta. 
Death  took  place  suddenly  on  the  fifth  day  from  perforation  of  the  aorta  and  haemor- 
rhage, after  a  slight  exertion.  Mr.  Eve  {Clin.  Soc.  Trans.,  vol.  xiii.  p.  174)  gives  a 
case  in  which  a  fish-bone,  impacted  in  the  oesophagus,  wounded  the  heart  fatally.  It 
was  thought  that  the  position  of  the  fish-bone  was  perhaps  due  to  previous  use  of  the 
probang. 


414  OPERATIONS    ON    THE    HEAD    AND    NECK. 

As  far  as  my  knowledge  goes,  the  lowest  point  from  which  a  foreign 
body  has  been  removed  occurred  in  the  practice  of  Mr.  Bennet  May. 
Here  a  child,  aged  seven,  had  swallowed  a  halfpenny  three  and  a  half 
years  before.  The  coin  had  ulcerated  through  the  oesophagus  and 
opened  the  right  bronchus,  lying  partly  in  this  and  partly  in  the 
oesophagus.  It  was  removed  successfully  by  oesophagotomy.  When 
the  foreign  body  has  been  removed,  the  question  of  introducing 
sutures  into  the  oesophagus  will  arise.  These  should  only  be  used 
when  the  wound  in  the  gullet  is  clean  cut,  not  bruised,  and  when  the 
body  has  been  quickly  removed  ;  the  sutures  should  be  of  fine  chromic 
gut  and  only  the  upper  part  of  the  wound  in  the  oesophagus  should  be 
closed,  the  rest  being  left  open  to  the  bottom  to  allow  of  free  drainage, 
owing  to  the  danger  of  sloughing,  pent-up  foul  secretions,  and  blood- 
poisoning  (p.  416).*  A  drainage-tube  should  be  inserted  to  the  bottom 
of  the  wound,  iodoform  dusted  on,  a  few  sutures  placed  in  the  edges 
of  the  wound,  dry  dressings  applied — viz.,  iodoform  gauze,  salicylic 
wool,  etc.,  if  the  wound  has  not  been  much  probed  about,  and  there 
is  thus  good  reason  to  expect  early  union.  But  if  ulceration  of  the 
soft  parts  has  been  found,  if  they  are  inflamed,  emphysematous,  etc., 
the  wound  should  be  left  open  to  the  very  bottom,  and  lint  soaked  in 
saturated  boracic-acid  solution  applied  and  frequently  wetted. 

After-treatment. — If  the  patient  is  in  good  condition,  if  the  for- 
eign body  has  been  removed  early,  or  if  the  patient  has  been  able  to 
swallow  liquids  in  the  interval  between  the  accident  and  the  ojDeration, 
he  may  be  fed  for  the  first  few  days  by  nutrient  enemata  and  nutrient 
suppositorieSjt  and  only  a  little  ice  given  occasionally  by  the  mouth. 
But  if  the  strength  is  not  satisfactory  at  the  time  of  the  operation,  or 


*  If  there  is  any  doubt  sutures  had  far  best  be  dispensed  with.  Dr.  Barton  {Ann. 
of  Surg.,  July,  1887)  has  recorded  the  case  of  successful  oesophagotomy  in  a  little  child 
— the  age  does  not  appear  to  be  given.  The  foreign  body,  a  small  steel  roller  of  a 
sewing-machine,  had  been  swallowed  three  months  before.  This  was  extracted  through 
a  very  small  opening  in  the  oesophagus  "  after  the  manner  of  working  a  stud  through 
a  button-hole  which  is  too  small  for  it,"  from  the  fear  of  causing  a  fistula  if  the  opening 
was  enlarged.  The  wounds  in  the  oesophagus  and  superjacent  parts  were  separately 
sutured.  Epileptic  fits  soon  followed,  and  frequent  vomiting  tore  open  tlie  wound. 
The  fits  having  ceased  with  the  administration  of  potassium  bromide,  the  wound  in 
the  oesophagus  was  pared  and  sutures  re-applied  as  before.  This  limited  much  the 
escape  of  fluids  through  the  wound,  but  did  not  entirely  stop  it.  The  passage  of  a 
tube  through  the  mouth  twice  a  day  caused  so  much  irritation  that  it  was  abandoned, 
and  tlie  tube  passed  through  the  wound.  The  wound  healed  slowly  though  surely. 
Dr.  Barton  is  inclined  to  recommend  this  way  of  feeding  when  primary  union  is  not 
secured. 

f  Of  these,  the  zyminized  meat  suppositories  of  Burroughs  &  Wellcome  are  amongst 
the  best. 


CESOPHAGOTOMY.  415 

if  the  eneraata  are  not  retained,  a  soft  feeding  tube  must  be  made  use 
of.  This  should  be  passed  by  tlie  mouth  and  retained,  if  not  very- 
uncomfortable  to  the  patient,  or  passed  at  intervals*  Towards  the 
end  of  the  first  week,  perhaps  earlier,  if  the  wound  is  healing  well, 
the  patient  may  be  allowed  to  swallow  a  little  diluted  wine  or  milk. 
Chief  Difficulties. 

1.  A  fat,  short  neck. 

2.  Enlarged  veins. 

3.  Wide  depressors  of  hyoid  bone. 

4.  Enlarged  thyroid  gland. 

5.  Unusual  depth  of  oesophagus. 

6.  Detecting  the  site  of  the  foreign  body. 

7.  Firm  gripping  of  the  body  by  the  oesophagus. 

8.  The  fact  that  the  foreign  body  may  be  dislodged  during  the  oper- 
ation. Dr.  Lediard  (Clin.  Soc.  Trans.,  vol.  xviii.  p.  297)  records  the 
case  of  a  man  in  whom  emetics  and  several  attempts  at  removal  had 
failed  to  dislodge  a  tooth-plate;  emphysema  of  the  neck  was  present, 
and  some  blood  on  the  forceps  used.  Just  before  oesophagotomy,  a 
bougie  was  thought  to  "  scrape  "  as  it  was  withdrawn.  Nothing  being 
felt  when  the  oesophagus  was  exposed,  a  bougie  was  passed,  and  the 
oesophagus  incised  behind  the  cricoid  cartilage ;  the  finger  now  could 
feel  nothing,  and  a  bougie  passed  on  seemed  to  feel  the  plate  near  the 
stomach.  The  plate  was  passed  19  days  after  its  impaction ;  it  meas- 
ured li  inch  by  f  inch,  carried  one  incisor,  and  had  ''  numerous  sharp 
points,  and  a  formidable  looking  hook  at  one  end."  Though  there 
were  no  laryngeal  symptoms,  the  plate  must  have  been  lying  behind 
the  lower  end  of  the  larynx,  as  the  mucous  membrane  of  the  gullet 
showed  here  several  ecchymoses.  The  dislodgment  of  the  plate  took 
place  either  during  the  passage  of  the  bougie  or  in  the  administration 
of  the  ana?sthetic.     The  patient  made  a  good  recovery. 

Causes  of  Death. — These  are  chiefly  : 

*  Dr.  Markoe  (Ann.  of  Surg.,  September.  1886),  in  the  case  of  a  man,  aged  twenty- 
four,  in  wliom  he  removed,  by  oesophagotomy,  half  a  tooth-plate,  which  had  been 
broken  in  eating,  passed  a  soft  india-rubber  tube  into  the  stomach  through  the  wound, 
replacing  this  by  one  passed  through  the  nose  on  the  tenth  day,  and  allowing  the 
patient  to  swallow  on  the  seventeenth  day  after  the  operation.  The  following  are  the 
reasons  given  for  passing  the  tube  through  the  wound  :  (1)  It  ensures  good  drainage 
from  the  bottom  of  the  wound ;  (2)  Anything  regurgitated  from  the  stomach  passes 
through  the  tube,  not  up  into  the  wound  ;  (3)  It  is  less  unpleasant.  The  above  reasons 
do  not  seem  to  me  to  outweigh  the  great  risks  and  disadvantages  of  irritating  and 
keeping  open  the  wound,  which  it  is  desirable  to  have  closed  as  soon  as  possible.  As 
a  rule,  the  tube  should  certainly  be  passed  from  the  mouth  or  nose.  It  is  noteworthy 
that  in  the  above  case  the  prolonged  lodgment  of  the  foreign  body — six  to  seven  weeks 
elapsing  between  the  accident  and  the  operation — had  not  caused  any  serious  abra- 
sion, etc. 


416  OPERATIONS    ON    THE    HEAD    AND    NECK. 

1.  SepticEemia*  The  wound  having  become  emphysematous, 
sloughy,  and  the  discharge  most  fouL 

2.  Exhaustion.  When  the  body  has  been  long  impacted,  and  the 
patient's  health  has  run  down  before  the  operation. 

CESOPHAGOSTOMY. 

This  has  been  proposed  as  a  substitute  for  gastrostomy.  Mr.  Reeves, 
who  brought  this  subject  before  the  Clinical  Society ,t  recommended 
this  operation  as  less  dangerous  than  gastrostomy,  and  in  the  belief 
also  that  cancer  of  the  oesophagus  is  most  frequently  met  with  in  the 
upper  part  of  the  tube. J  The  objections,  however,  are  so  great  as  to 
have  prevented  any  adoption  of  this  operation.  They  are — (1)  the 
risk  of  coming  close  to  a  mass  of  cancer,  which  will  not  only  not  admit 
of  dilatation,  but  which  will  be  rendered  more  active,  sloughy,  etc.,  by 
the  necessary  irritation.  (2)  The  fact  that  important  parts  are  close 
by,  and  that  the  relations  of  these  may  very  likely  be  much  altered. 
(3)  The  probability  of  finding  the  oesophagus  altered  near  the  disease, 
and  thus,  perhaps,  readily  perforated,  admitting  fluids  into  the 
pleura,  etc. 

(ESOPHAGECTOMY. 

This  is  another  operation  which  has  been  introduced  only  to  be 
abandoned.  Prof.  Czerny's  case,  it  is  true,  was  temporarily  successful, 
the  patient  living  rather  more  than  a  year  after  the  operation.  But 
cases  equally  suitable  from  the  site  of  the  disease — only  just  out  of 
reach  of  the  finger  introduced  from  the  mouth — with  no  glands  in- 
volved, and  no  adhesions  to  adjacent  parts,  though  symptoms  had 
lasted  five  months,  must  be  quite  exceptional.  Several  of  the  risks 
given  above  would  be  intensified  here,  and  there  would  be  present  as 
well  the  need  of  keeping  the  fistula  patent.§ 

*  Mr.  Butliii  (Clin.  Soc.  Trans.,  vol.  xvii.  p.  129)  relates  a  case  in  which  a  tooth-plate 
was  removed  within  twenty-four  honrs  of  its  being  swallowed,  previous  attempts  at 
removal,  lasting  thirty  or  forty-five  minutes,  having  failed.  No  difficulty  was  experi- 
enced during  the  operation,  but  the  patient  sank  from  septicaemia  four  days  after  the 
operation.  He  was  allowed  to  swallow  on  the  second  day,  about  a  third  of  what  was 
taken  coming  through  the  wound.  Mr.  Butlin  considered  this  beneficial,  as  conducing 
to  drainage.  The  wound  was  thoroughly  washed  with  carbolic  lotion  and  covered  with 
carbolic  oil.  Two  days  after,  the  wound  being  very  offensive,  the  dressing  was  altered 
to  Sanitas,  changed  every  four  hours. 

t   Trans.,  vol.  xv.  p.  26. 

X  Most  surgeons  who  have  been  called  upon  to  pass  bougies  in  these  cases  will  agree 
with  Dr.  Goodhart,  who,  in  the  discussion  on  the  above  paper,  said  the  disease  usually 
extended  from  the  cricoid  cartilage  nearly  to  the  pylorus. 

§  Mr.  Butlin  '  Oper.  Surg.  Malig.  Dis.),  to  whom  I  am  indebted  for  Prof.  Czerny's 
case,  gives  one  of  Prof  Billroth's,  where  death  was  caused  by  the  passage  of  the 
bougie  into  the  tissues  round  the  oesophagus,  the  opening  where  the  lower  end  of  the 
oesophagus  had  been  stitched  to  the  skin  having  contracted. 


OPERATIONS   ON   THE  SPINAL   ACCESSOEY.  417 

CHAPTER  XVI. 

OPERATIONS  ON  THE  SPINAL  ACCESSORY 
NERVE. 

DIVISION  OR  NERVE-STRETOHINQ. 

Indications. — In  cases  of  spasmodic  torticollis  in  which 

1.  All  previous  palliative  treatment  has  failed — e.g.,  large  doses  of 
conium,  massage,  galvanism  of  the  n fleeted  side  and  faradization  of 
the  opposite  muscles. 

2.  The  spasms  are  so  severe  and  constant  as  to  interfere  with  the 
patients  taking  food  or  enjoying  sleep,  and  to  cause  sad  weariness  and 
real  suffering. 

3.  The  only  muscles  affected  are  the  sterno-mastoid,  or  the  sterno- 
mastoid  and  trapezius. 

Anatomy  of  Spinal  Accessory  Nerve. — The  spinal  or  external 
part  of  this  nerve,  having  left  the  skull  by  the  jugular  foramen,  is 
directed  backwards  in  front  of,  or  behind,  the  internal  jugular  vein, 
and  appears  below  the  digastric  and  the  occipital  artery.  It  then 
descends  obliquely  outwards  to  the  sterno-mastoid  muscle  and  dis- 
appears under  this  at  a  distance  of  2  inches  from  the  apex  of  the  mas- 
toid process.  Having  usually  perforated  the  muscle  the  nerve  passes- 
across  the  posterior  triangle  to  end  in  the  deep  surface  of  the  trapezius. 

While  passing  through  or  under  the  sterno-mastoid  the  nerv^e  joins- 
with  branches  from  the  second  cervical.  Having  emerged  from  the 
muscle  it  joins  with  the  second  and  third  nerve,  and  is  often  in  inti- 
mate connection  with  the  great  auricular  and  small  occipital.  When 
under  the  trapezius  it  is  joined  by  branches  of  the  third  and  fourth 
cervical. 

Operations  for  Division  or  Stretching  of  the  Nerve.^ 

These  maybe  considered  together,  but  it  may  be  said,  once  for  all,  that 
as  stretching  will  be  followed  by  but  temporary  benefit,  division  of  the 
nerve  will  be  the  better  operation. 

The  nerve  may  be  found  for  these  purposes  by  two  different 
incisions. 

A.  By  one  made  along  the  anterior  border  of  the  sterno-mastoid 
so  as  to  come  upon  this  nerve  before  it  perforates  this  muscle.. 

B.  By  one  along  the  posterior  border  of  the  muscle,  the  surgeon, 
finding  the  nerve  as  it  emerges  here  to  cross  the  posterior  triangle  to 
gain  the  trapezius,  and  following  it  up  into  the  sterno-mastoid,  so  as 
to  paralyze  this  muscle  also. 

The  first  of  these  operations  is  in  my  opinion  much  preferable,  and 
for  these  reasons : 

1.  Though  the  nerve  lies  more  deeply  at  the  anterior  than  at  the 

27 


418  OPERATIONS    ON    THE    HEAD    AND    NECK. 

posterior  border  of  the  muscle,  it  is  here  a  single  nerve,  and  not  likely 
to  be  confounded  with  other  nerves — e.g.^  branches  of  the  third  cervical, 
which  also  emerge  at  the  posterior  border  to  supply  the  skin.  Fur- 
thermore, in  this  latter  position,  the  spinal  accessory  is  often  found  in 
close  connection  with  the  small  occipital  and  great  auricular,  as  these 
two  nerves  appear  at  the  posterior  border  and  curve  upwards. 

2.  By  finding  the  nerve  at  the  anterior  border  of  the  muscle  paral- 
ysis of  the  sterno-mastoid  is  better  ensured.  When  the  nerve  is  found 
at  the  posterior  border  and  followed  up  into  the  muscle  before  division, 
there  is  always  a  certain  amount  of  uncertainty  as  to  whether  some 
branch  to  the  muscle  may  not  have  come  off  above  the  point  at  which 
the  surgeon  has  divided  the  nerve. 

A.  Operation  above  Sterno-mastoid. — The  parts  being  shaved 
and  cleansed,  and  the  head  suitably  raised  and  turned  to  the  opposite 
side,  the  surgeon  makes  an  incision  along  the  anterior  border  of  the 
sterno-mastoid  for  3  inches,  commencing  at  the  apex  of  the  mastoid 
process.  Skin,  fasciae,  and  platysma  being  divided,  the  anterior  border 
of  the  sterno-mastoid  is  clearly  defined  and  drawn  strongly  backwards, 
so  as  to  put  the  nerve  on  the  stretch ;  the  wound  being  sponged  out 
dry,  the  nerve  is  found,  and  from  k  to  J  inch  removed. 

If  there  is  any  doubt  about  finding  or  identifying  the  nerve,  the 
following  aids  may  be  found  useful — viz.,  defining  the  lower  border 
of  the  digastric  and  the  occipital  artery,  remembering  the  direction  of 
the  nerve,  and  looking  for  it  at  a  point  2  inches  below  the  apex  of  the 
mastoid  process.* 

B.  Operation  Below  or  at  Posterior  Border  of  Sterno- 
mastoid. — Mr.  Campbell  de  Morgan,  who  introduced  this  operation 
into  British  surgery  with  a  very  successful  case,t  made  an  incision  2 
inches  long,  along  the  posterior  border  of  the  sterno-mastoid,  the 
centre  of  the  incision  corresponding  to  about  the  cenlre  of  this  border 
of  the  muscle.  The  fascia  being  slit  up  to  the  same  extent  the  trape- 
zial  branch  of  the  nerve  was  sought  for  as  it  emerges  from  the  sterno- 
mastoid  to  cross  the  posterior  triangle.  It  will  be  found  generally  a 
little  above  the  centre  of  the  wound,  when  found  it  is  traced  through 
the  muscle  till  the  common  trunk  is  discovered  above  its  division  into 
branches  for  the  trapezius  and  sterno-mastoid.  Half  an  inch  of  the 
nerve  is  then  cut  out. 

If  called  upon  to  perform  this  operation  again,  I  should  certainly 
prefer  the  firat  of  the  two  methods  given  above,  as  being  more  certain, 

*  Ballance,  he.  infra  cit. 

t  Brit,  and  For.  Med.-Ckir.  Rev.,  July,  1886.  I  performed  the  same  operation  on  a 
middle-aged  woman  abont  eleven  years  ago  at  Guy's  Hospital  in  a  very  severe  case  of 
spasmodic  torticollis.  The  right  sterno-mastoid  and  trapezius  were  paralyzed  and 
rendered  quiescent,  but  some  of  tiie  deeper  muscles  on  the  opposite  side — viz.,  the 
splenii — became  affected,  and  no  permanent  benefit  resulted. 


IJGATURE    OF    TEMPORAL   ARTERY.  419 

and  as  not  really  more  difficult.  Though  the  nerve  is  more  superficial 
in  the  posterior  triangle  it  is  difficult  to  make  certain  whether  it  is  the 
spinal  accessory  or  one  of  the  superficial  cervical  nerves  which  emerge 
close  to  it,  from  behind  the  muscle  (p.  417). 

The  most  interesting  contribution  to  the  literature  on  this  subject 
is  a  paper  by  Mr.  Ballance.*  His  patient,  a  woman  of  forty-eight, 
was  a  good  instance  of  the  distress  and  misery  due  to  spasmodic  tor- 
ticollis. Division  of  the  right  spinal  accessory  in  the  anterior  triangle 
gave  most  decided  relief.  At  the  end  of  four  months,  when  the  history 
ceases,  the  patient  is  reported  to  have  been  "  much  better  and  stouter. 
The  face  is  hai)py  and  tranquil.  There  is  neither  headache  nor  pain, 
and  sleep  and  appetite  are  good.  The  control  of  the  movements  of 
the  head  is  perfect  as  long  as  she  is  not  excited,  and  so  long  as  the 
head  is  not  raised  so  that  the  eyes  are  directed  much  above  the  hori- 
zontal plane  in  which  they  lie The  right  sterno-mastoid  and 

trapezius  are  atrophied." 

Division  of  the  spinal  accessory  deserves  a  further  trial,  even  if  the 
relief  given  is  not  permanent. 

The  chief  fear  is  that  other  muscles  will  become  involved.  Thus, 
Mr.  Ballance  writes  of  his  case :  "  Since  the  operation,  it  has  been  cer- 
tain that  some  of  the  muscles  supplied  by  the  upper  spinal  nerves 
are  liable  to  spasm.  It  would  be  strange  if  it  were  not  so,  considering 
the  intimate  connections  between  the  second,  third,  and  fourth  spinal 
nerves,  and  the  spinal  accessory  in  the  sterno-mastoid,  trapezius,  and 
posterior  triangle,  together  with  the  fact  that  some  of  the  fibres  of  the 
spinal  accessory  are  connected  with  the  same  cells,  or  with  cells  in 
the  immediate  neighborhood  of  those  from  which  arise  the  motor 
rootlets  of  the  cervical  spinal  nerves." 


CHAPTER  XVII. 

LIGATURE  OP  THE  ARTERIES  OP  THE  HEAD  AND 

NECK. 

LIGATURE  OF  THE  TEMPORAL  ARTERY  (Fig.  89).t 

Indications. — These  are  very  few,  viz. ; 

1.  Wounds— c.^.,  stabs  and  gunshot  injuries. 

2.  Aneurism,  usuall}^  traumatic.     Mr.  Skey  J  met  with  a  case  of 

*  St.  Thomas's  Hasp.  Reports,  vol.  xiv.  p.  95.  Other  successful  cases  will  be  found 
recorded  by  Prof.  Annandale  {Lancet,  1879,  vol.  i.  p.  555),  Mr.  Southara  {Ibid.,  1881, 
vol.  ii.  p.  369) ;  Mr.  Kivington  also  operated  {Ibid.,  1879,  vol.  i.  p.  '213),  but  phleg- 
monous erysipelas  carried  oif  the  patient  before  the  wound  was  quite  healed. 

t  Ligature  of  the  thyroid  arteries  has  already  been  considered,  chap.  xiii.  p.  400. 

t   Oper.  Surg.,  p.  289. 


420  OPERATIONS    ON   THE    HEAD   AND   NECK. 

aneurism  of  doubtful  origin  in  this  artery  in  a  young  lady.  Ligature 
of  the  vessel  below  having  failed,  he  cured  his  patient  by  the  means  of 
a  fine  spring  compress  with  a  ball-and-socket  joint  which,  passing  over 
the  head,  entirely  concealed  by  the  hair,  made  pressure  on  the  tumor. 

Aneurisms  have  been  known  to  occur  here  after  the  operation  of 
arteriotomy. 

Guide. — A  line  drawn  upwards  over  the  root  of  the  zygoma,  mid- 
way between  the  condyle  of  the  jaw  and  the  tragus. 

Relations. — Given  off  behind  the  jaw,  this  vessel  passes  up  midway 
between  the  above  two  points  over  the  zygoma,  and  at  a  point  IJ  or  2 
inches  higher  up  it  divides  into  its  anterior  and  posterior  branches. 
Lying  at  first  in  the  parotid  gland  it  is  covered  a  little  higher  up  by 
a  dense  fascia  passing  from  the  parotid  to  the  ear,  by  the  attrahens 
aurem,  often  a  lymphatic  gland,  and  one  or  two  veins  which  lie  super- 
ficial but  close  to  it.  Some  branches  of  the  facial  nerve  cross  it,  while 
the  auriculo-temporal  nerve  accompanies  it  closely.  Higher  up  the 
artery  and  its  branches  are  particularly  subcutaneous. 

Operation  (Fig.  89). — The  parts  being  shaved  and  cleansed,  the 
head  fitly  supported  and  turned  to  the  opposite  side,  an  incision 
about  1  inch  long  is  made  in  the  line  of  the  artery  so  as  to  tie  it  just 
above  the  zygoma.  The  dense  subcutaneous  tissue  and  the  strong 
parotid  fascia  being  cleanly  divided  the  artery  must  be  accurately 
defined,  and  the  vein  being  drawn  to  one  side,  usually  backwards,  the 
ligature  should  be  passed  from  behind  forwards,  care  being  taken  to 
include  only  the  artery. 

Arteriotomy. — A  few  words  may  be  said  here  about  this  seldom- 
used  operation.  The  surgeon,  having  defined  the  anterior  division  of 
the  temporal,  steadies  the  vessel  by  placing  his  finger  just  beyond  the 
point  which  he  intends  to  open,  and  then  with  a  small  sharp  scalpel 
lays  open  the  vessel  till  it  is  about  half  cut  through.  The  blood 
required  having  been  removed,  he  divides  the  vessel  completely,  so  as 
to  allow  the  ends  to  retract,  applies  a  pad  of  aseptic  gauze  or  of  lint 
and  iodoform,  and  retains  this  in  position  with  the  twisted  or  knotted 
bandage  for  the  head.  The  pad  should  not  be  removed  for  four  or 
five  days. 

The  reasons  for  preferring  the  anterior  division  to  the  trunk  of  the 
vessel  are  the  following  : 

(1)  The  latter  lies  much  more  deeply,  under  fascia3,  and  in  the 
parotid  below ;  thus  so  much  pressure  may  be  required  to  stop  the 
bleeding  as  to  cause  sloughing,  secondary  hsemorrhage,  and  dangerous 
erysipelatous  inflammation. 

(2)  Injury  to  one  of  the  adjacent  nerves  may  cause  severe  pain  and 
tedious  healing. 

(3)  From  o})ening  a  vein  at  the  same  time  an  anterio-venous  aneu- 
rism may  result. 


LIGATUEE   OF   FACIAL   AND   OCCIPITAL   ARTERIES.  421 

LIGATURE  OP  THE  FACIAL  ARTERY  (Fig.  89). 

Indications. — These  are  much  the  same,  but  still  fewer  than  those 
for  ligature  of  the  temporal  artery.* 

The  vessel's  course  is  divided  into  a  cervical  and  a  facial  part. 

Cervical  Part. — Ligature  here  can  be  scarcely  ever  required. 
The  vessel  could  be  reached  here  by  an  incision  similar  to  that  for 
the  external  carotid  (infra),  or  the  lingual  (p.  424).  In  either  of 
these  cases  the  vessel  would  be  found  just  below  the  posterior  belly  of 
the  digastric  and  the  stylo-hyoid,  these  muscles  being  drawn  upwards 
to  enable  the  surgeon  to  tie  the  vessel  just  before  it  enters  the  sub- 
maxillary gland. 

Relations  in  the  Neck. — The  facial  artery  is  given  off  just  above 
or  in  connection  with  the  lingual,  about  an  inch  above  the  bifurcation 
of  the  common  carotid.  It  ascends  upwards  and  inwards  to  the  lower 
jaw,  being  covered  by  skin,  ftisciw,  and  platysma,  the  digastric  and 
stylo-hyoid,  and  being  embedded  in  the  sub-maxillary  gland,  to  which 
structure  the  vein  lies  superficial.  The  tortuous  outline  of  the  vessel 
is  well  known.  The  vein,  running  a  straighter  course,  lies  posterior 
to  the  artery. 

Facial  Portion. — The  artery  is  readily  secured  by  an  incision 
about  1  inch  long  just  in  front  of  the  masseter  muscle,  the  anterior 
border  of  which  should  be  first  defined,  this  being  easily  done  on  the 
living  subject  by  telling  the  patient  to  throw  it  into  action.  The  inci- 
sion should  be  made  carefully  so  as  to  allow  of  any  branches  of  the 
facial  nerve  which  may  lie  in  the  way.  The  artery  will  now  be  felt 
when  rolled  upon  the  bone  by  a  finger ;  the  ligature  should  be  passed 
from  behind  forwards  so  as  to  avoid  the  adjacent  vein. 

If  there  is  any  especial  object  for  avoiding  the  small  scar  which  this 
operation  entails,  the  vessel  ma}^  be  reached  by  a  horizontal  incision 
just  below  the  jaw  in  front  of  the  masseter  muscle;  a  method  which 
also  places  the  incision  parallel  to  the  branches  of  the  facial  nerve. 

LIGATURE  OF  OCCIPITAL  ARTERY  (Fig.  89). 

Indications. 

1.  Stabs. 

2.  Gunshot  wounds.  In  the  Medical  and  Surgical  History  of  the  War 
of  the  Eebellion,  part  i.  p.  422,  two  cases  are  given  of  secondary  haemor- 
rhage after  wounds  of  the  neck,  in  the  one  case  from  the  occipital,  in 
the  other  from  a  branch  of  it ;  in  the  former  case  16  ounces  of  blood 

*  Tlie  reader  is  advised  to  take  every  opportunity  afTorded  upon  the  dead  body  to 
tie  these  and  other  arteries,  though  apparently  so  small  and  unimportant,  as  only  by 
such  practice  can  dexterity  be  really  acquired. 


422  OPERATIONS   ON    THE    HEAD    AND    NECK. 

were  lost.     The  vessel  was  tied  in  the  wound  in  each  case,  two  liga- 
tures being,  of  course,  applied. 

3.  In  the  treatment  of  arterial  varix,  cirsoid  aneurism,  or  aneurism 
by  anastomosis  on  the  head  (p.  448). 

4.  For  haemorrhage  from  an  abscess  in  the  neck.  Mr.  Banks*  has 
published  a  most  instructive  case  of  this  kind.  A  weakly  man,  aged 
thirty-two,  had  had  a  suppurating  gland  incised  three  weeks  before 
admission.  Poultices  were  applied,  and,  a  week  after,  during  a  violent 
attack  of  coughing,  blood  burst  from  the  wound  "  like  a  tap  being 
turned  on."  Three  times  afterwards  haemorrhage  ensued,  pressure 
being  applied  in  vain.  On  admission  he  was  in  the  last  stage  of 
exhaustion.  The  right  side  of  the  neck  from  ear  to  clavicle  was  occu- 
pied by  a  great  fluctuating  swelling.  In  front  of  the  sterno-mastoid, 
about  half-way  down,  was  the  original  incision,  from  which  a  little 
sanious  discharge  was  issuing.  Behind  the  muscle  a  piece  of  skin 
about  an  inch  square  was  actually  sloughing  from  the  subjacent  pres- 
sure. Under  ether,  and  in  a  good  light,  the  original  incision  was  en- 
larged upwards  and  downwards,  and  a  quantity  of  putrid  broken- 
down  clot  turned  out.  Then  a  similar  incision  was  made  behind  the 
sterno-mastoid  through  the  slougliing  skin.  Everything  being 
mopped  and  cleaned  up,  blood  was  found  to  be  trickling  down  from 
somewhere  very  high  up.  To  get  at  it,  the  sterno-mastoid  and  skin 
over  it  were  cut  clean  across,  thus  uniting  the  two  vertical  incisions 
by  a  transverse  one.  The  muscle  was  dissected  upwards,  exposing 
the  sheath  of  the  carotid  vessels,  but  still  the  blood  always  kept  run- 
ning from  some  deep-seated  point  high  up.  At  last  this  was  reached, 
just  in  front  of  the  transverse  process  of  the  atlas.  From  it  arterial 
blood  issued,  and  an  aneurism  needle  was  thrust  through  the  tissues 
on  each  side  of  it  and  ligatures  applied,  which  at  once  checked  all 
further  bleeding.  The  vessel  was  the  occipital  artery  not  far  from  its 
origin.  Into  it  the  abscess  had  made  its  way.  The  great  wound  was 
rapidly  swabbed  out  with  turpentine  and  then  stuffed  with  lint  dipped 
in  the  same  fluid.  The  patient  was  very  near  to  death's  door,  but 
ultimately  recovered.! 

*  Clinical  Notes  upon  Two  Years'  Surgical  Work  at  The  Liverpool  Royal  Infirmary,  p. 
161. 

f  Such  was  the  patient's  condition  that  tlie  surgeon  was  quite  prepared  for  his  dying 
under  the  operation.  The  following  characteristically  vigorous  words  conclude  the 
account — "But  I  was  determined,  as  long  as  he  had  any  blood  to  run  out  of  him,  the 
place  whence  it  came  should  be  found  and  tied."  In  connection  with  this  case  may  be 
quoted,  in  his  own  words,  some  remarks  of  Mr.  Banks  on  Ihe  value  of  turpentine  as  a' 
cleansing  styptic.  This  remedy  has  again  lately  been  recommended,  and  it  is  only  fair 
that  Mr.  Banks  should  have  the  credit  of  having  recognized  its  value  six  years  ago- 
"  In  former  days  it  was  the  regular  thing  for  oozing,  until  superseded  by  the  introduc- 


LIGATURE   OF    OCCIPITAL    ARTEEY.  423 

Relations. — A  posterior  branch  of  the  external  carotid,  the  occip- 
ital conies  off  opposite  to  or  a  little  above  the  facial,  just  below  the 
digastric.  It  at  first  ascends,  having  the  ninth  nerve  hooking  round 
it,  under  cover  of  the  digastric,  stylo-hyoid  and  parotid,  and  crossing 
the  internal  carotid,  internal  jugular,  vagus,  and  spinal  accessory. 
Having  reached  the  interval  between  the  transverse  process  of  the 
atlas  and  the  mastoid  bone,  it  now,  in  the  second  part  of  its  course, 
turns  horizontally  backwards,  grooving  the  temporal  bone,  covered  by 
the  sterno-mastoid,  splenius,  digastric  andtrachelo-mastoid,and  lying 
on  the  complexus  and  superior  oblique.  In  the  third  part  of  its 
course  it  runs  vertically  upwards,  piercing  the  trapezius,  and  ascend- 
ing tortuously  in  the  scalp. 

Operation. 

1.  If  the  artery  require  secviring  low  down,  this  may  be  effected 
much  as  in  tying  the  external  carotid,  an  incision  being  made  along 
the  anterior  border  of  the  sterno-mastoid,  the  deep  fascia  opened,  and 
the  digastric  and  ninth  nerve  exposed.  Care  should,  of  course,  be 
taken  to  avoid  the  latter. 

2.  To  tie  the  artery  behind  the  mastoid  process  (Fig.  89),  e.f/.,  when 
it  has  been  wounded  by  a  stab  in  the  neck,  the  following  steps  should 
be  taken:  The  parts  being  shaved,  and  the  head  at  first  being  placed 
in  much  the  same  position  as  for  ligature  of  the  carotids,  an  incision 
is  made  from  the  tip  of  the  mastoid  process  rather  obliquely  upwards, 
so  as  to  lie  over  a  point  midway  between  the  mastoid  and  external 
occipital  protuberance.  The  tough  skin  and  fascire  being  incised,  the 
posterior  half  of  the  sterno-mastoid,  with  its  strong  aponeurosis,  and 
next  the  splenius  capitis,  must  be  divided,  together  with  any  fibres  of 

tion  of  perchloride  of  iron.  This  lias  iilways  seemed  to  me  most  unfortunate,  as  iron 
istbevery  worst  of  all  styptics.  Owing  to  its  great  potency  and  the  rapidity  witli  which  it 
acts,  it  soon  became  popular,  and  is  at  the  present  moment  the  favorite  standby  of  the 
chemist,  who  diligently  swabs  with  it  every  cut  that  is  brought  into  his  shop,  prepara- 
tory to  sending  the  patient  off  to  a  hospital.  As  a  result,  the  wound  is  covered  with  a 
cake  of  coagulated  blood,  and  its  surfaces  are  sometimes  positively  killed  by  the 
strength  of  the  application.  Beneath  this  firmly  adherent  crust  all  sorts  of  purulent, 
filthy  secretions  accumulate,  till  at  the  end  of  forty-eight  hours  it  stinks  abominably, 
and  requires  to  be  well  poulticed  to  get  it  clean.  Should  bleeding  recur,  the  difficulty 
of  finding  the  spot  is  enormously  increased  by  the  mass  of  pus  and  almost  cineritious 
hard  clots  which  cover  it.  I  have  seen  so  many  cut  hands  almost  ruined  by  it  that  I 
have  totally  abandoned  it.  On  the  other  hand,  turpentine  is  nearly  as  powerful  a 
styptic,  and  is  a  most  marvellous  cleanser  and  sweetener.  The  plug  soaked  in  turpen- 
tine comes  out  quite  easily  at  the  end  of  four-andtwenty  hours,  leaving  a  wholesome 
surface  behind  it.  For  all  wounds  about  the  perinaeum,  such  as  lithotomy  wounds, 
fistula,  cuts,  or  incisions  for  extravasation  of  urine,  there  is  nothing  like  it,  and  I  trust 
it  will  soon  be  reinstated  in  surgical  favor.  Our  forefathers  had  some  excellent  reme- 
dies, and  this  is  one  of  them," 


424  OPERATIONS   ON   THE   HEAD   AND   NECK. 

the  trachelo  mastoid  that  are  in  the  way.  The  wound  being  some- 
what relaxed  by  turning  the  head  over  to  this  side,  retractors  deeply 
inserted,  and  a  laryngeal  mirror  used  if  needful,  the  artery  will  be 
found  deep  down  between  the  mastoid  bone  and  the  transverse  pro- 
cess of  the  atlas. 

In  separating  it  from  its  vein,  one  or  more  veins  varying  in  size  may 
be  met  with,  forming  communications  between  the  occipital  and  mas- 
toid veins,  and  thus  with  the  lateral  sinus.  The  importance,  therefore, 
of  keeping  the  wound  rigidly  aseptic  is  obvious. 

LIGATURE  OF  THE  LINGUAL  ARTERY  (Fig.  86). 

Indications. 

1.  Before  removal  of  the  tongue.  This  subject  has  been  considered 
at  p.  333. 

2.  After  removal  of  the  tongue,  to  arrest  haemorrhage. 

3.  In  cases  of  tongue  cancer  not  admitting  of  operation,  in  the  hope 
of  checking  the  rate  of  growth,  diminishing  the  foetor,  profuse  saliva- 
tion, etc.  This  step  is  uncertain  as  to  the  amount  of  good  which  it 
effects,  and  any  good  that  it  may  do  will  not  be  long  lived.* 

4.  In  cases  of  macroglossia  this  operation  may  be  tried  before  re- 
moving a  wedge-shaped  piece  of  the  tongue  :  it  would  require  to  be 
performed  on  both  sides,  and  would  be  attended  with  considerable 
difficulty  in  a  child. 

Relations. — The  lingual  artery  arises  about  t  inch  above  the  supe- 
rior thyroid,  often  in  common  with  the  facial,  and  at  a  point  opposite 
to  the  great  cornu  of  the  hyoid  bone.  It  first  ascends  to  a  point 
rather  above  the  level  of  the  hyoid  bone,  then  descends  somewhat  and 

*  Mr.  Haward  {CUn.  Soc.  Trans.,  vol.  x.  p.  129)  relates  a  case  in  which  he  tied  the 
left  lingual  artery  for  recurrent  epithelioma.  The  recurrent  growth  was  the  size  of 
half  a  walnut  when  the  lingual  artery  was  tied.  It  at  once  ceased  to  grow,  became 
pale,  and  in  a  few  days  was  sloughing.  Gradually  separation  of  the  growth  went  on, 
until  the  aflfected  side  of  the  root  of  the  tongue  became  even  smaller  than  the  sound 
side,  and  eventually  the  part  healed.  A  fortnight  after  this  took  place,  or  three 
months  after  the  ligature  of  the  artery,  the  patient  died  of  pyaemia,  set  up  by  erysipe- 
las coming  on  after  the  operation.  Mr.  Haward  points  out  that  the  greater  part  of  the 
tongue  had  been  removed  before  the  ligature  of  the  lingual,  so  that  therefore  the 
an.astomoses  between  the  arteries  of  the  two  sides  would  be  greatly  diminished.  I 
think,  also,  that  the  fact  that  Mr.  Haward  was  obliged  to  tie  the  artery  close  to  the 
external  carotid,  may  have  contributed  to  the  sloughing,  by  cutting  off  the  entire 
blood-supply,  especially  that  through  the  dorsalis  linguae. 

On  the  other  hand,  Billroth  (Clin.  Surg.,  p.  113)  states  that  in  one  case  of  cancer  of 
the  tongue,  "  the  lingual  artery  was  ligatured  on  both  sides,  in  the  hope  that  the  infil. 
tration  of  the  tongue  in  the  cavity  of  the  mouth  might  diminish.  However,  the  liga- 
ture led  to  no  good  results,  nor  did  any  rapid  breaking-down  of  the  already  ulcerated 
new  formation  occur." 


LIGATURE   OF    LINGUAL    AETERY, 


425 


runs  just  above  the  great  cornu,  and  finally  ascending  to  the  under 
surface  of  the  tongue,  it  runs  forward  with  a  tortuous  course  to  the 
tip  as  the  ranine. 

For  practical  purposes  the  relations  of  the  artery  may  be  subdivided 
into  three  parts,  the  first  before  it  gets  under  the  hyo-glossus,  the 
second  while  it  lies  beneath  this  muscle,  and  the  third  beyond  this 
muscle. 

In  the  first  it  runs  very  deeply,  though  only  covered  by  the  skin, 
platysma  and  fasciae,  facial,  lingual,  and  some  pharyngeal  veins ;  it 
lies  upon  the  middle  constrictor  and  the  external  laryngeal  nerve. 
In  the  second  part  of  its  course  the  artery  again  lies  upon  the  middle 

Fig.  86.* 


The  sub-maxillary  gland  is  seen  in  the  upper  part  of  the  wound.  Below  this  is  the  hypo-glossal 
on  the  cut  hyo-glossus.  A  ligature  is  passed  between  the  lingual  artery  and  vein.  A  hook 
depresses  the  great  cornu  of  the  hyoid  bone. 

constrictor,  and  is  now  covered  by  the  hyo-glossus,  hypo-glossal,  part 
of  the  mylo-hyoid  and  the  lower  border  of  the  sub-maxillary  gland. 
From  this  part  come  off  the  four  branches  of  the  artery,  the  hyoid  at 
the  outer  or  posterior  edge  of  the  hyo-glossus,  the  dorsalis  linguae 
under  this  muscle,  and  the  sub-lingual  and  ranine  at  its  anterior 
border,  thus  allowing  room  for  placing  a  ligature. 

The  third  part  lies  in  the  mouth,  and  runs  along  the  under  surface 
of  the  tongue  up  to  the  point  of  the  fra?num.  It  is  only  covered  by 
mucous  membrane.  A  vein  runs  with  it  and  a  large  branch  of  the 
gustatory  nerve. 

Operations. 

i.  Ligature  under  the  Hyo-glossus. 

ii.  Ligature  of  the  first  part  of  the  Artery. 

*  The  lingual  artery  is  here  drawn  too  large,  and  too  much  of  the  vessel  is  shown 
cleaned  ;  the  depth  of  the  wound  is  not  sufficiently  represented. 


426  OPERATIONS   ON   THE    HEAD    AND    NECK. 

i.  The  vessel  is  usually  tied  while  under  the  hyo-glossus 
muscle,  owing  to  the  useful  guide  which  the  great  cornu  of  the  hyoid 
bone  forms,  and  this  is  the  operation  which  will  be  described  here 
(Fig.  86).  Under  some  circumstances  (p.  427)  it  will  be  needful  to 
seek  it  nearer  its  origin  from  the  external  carotid.  The  parts  being 
shaved,  the  head  suitably  supported  and  turned  to  the  opposite  side, 
the  lower  jaw  firmly  closed,  the  surgeon,  standing  or  seated  on  the 
same  side,  steadies  the  tissues  between  his  left  finger  and  thumb  and 
makes  a  curved  incision  with  its  centre  just  above  the  great  cornu  of 
the  hyoid  bone  (a  point  previously  carefully  noted)  and  reaching,  e.g., 
on  the  left  side,  from  just  below  and  to  the  left  of  the  symphysis 
downwards,  backwards,  and  then  upwards  towards  the  angle  of  the 
jaw,  ending  just  anteriorly  to  the  line  of  the  facial  artery. 

The  incision  divides  skin,  superficial  fascia,  and  platysma ;  the  deep 
fascia  is  then  opened  and  any  branches  of  the  anterior  jugular,  facial, 
or  communicating  branch  with  the  temporo-maxillary  vein  are  secured 
carefully  so  that  the  wound  may  be  kept  as  dry  as  possible.  The 
lower  border  of  the  sub-maxillary  gland,  which  probably  projects  into 
the  wound,  is  turned  upwards*  and  the  hypo-glossal  nerve  sought  for 
which  lies  deeper,  and  is  a  good  guide  to  the  hyo-glossus.  Lower  down 
in  the  neck  is  the  glistening  tendon  of  the  digastric  attached  to  the  hyoid 
bone.  The  hyo-glossus  being  defined,  the  hyoid  bone  is  carefully 
steadied  by  a  finger-nail  or  tenaculum,  a  director  passed  under  the 
hyo-glossus,  and  this  muscle  divided  cautiously.  In  doing  this  the 
lingual  vein  must  be  carefully  looked  for  either  on  the  muscle  or 
beneath  it,  with  the  artery.  The  artery  having  been  found  under  the 
muscle  just  above  the  hyoid  bone,  it  should  be  traced  backwards  so  as 
to  apply,  if  possible,  the  ligature  behind  the  origin  of  the  dorsalis  lin- 
guae. Adequate  drainage  must  be  provided,  and  every  care  taken  to 
prevent  decomposition  in  a  wound  so  deep  and  opening  up  several 
planes  of  deep  cervical  fascia. 

Any  enlarged  glands  will,  of  course,  be  removed. 

Guides  and  Aids  to  finding  the  Artery. 

1.  A  suflftciently  free  incision. 

2.  Carefully  defining  the  hypo-glossal  nerve,  and  remembering  the 
relative  position  of  the  sub-maxillary  gland,  the  digastric  tendon,  and 
the  great  cornu  of  the  hyoid  bone. 

3.  Keeping  the  wound  bloodless. 
Difficulties. 

1.  Matting  of  the  parts  from  old  cellulitis. 

2.  Presence  of  large  veins. 

*  The  sub-maxillary  gland  should  be  gently  handled,  and  not  cut  into.  In  the  one 
case  troublesome  swelling,  in  the  other  temporary  weeping  of  saliva,  or  even  a  fistula, 
will  be  the  result. 


LIGATURE    OF    THE    COMMON   CAROTID.  427 

3.  Depth  of  the  wound,  and  oozing  low  down  from  the  severed 
hj^o-glossiis. 

4.  In  one  case  Dr.  Shepherd "^  found  the  digastric  so  extensively 
tied  down  to  the  hyoid  bone  by  the  deep  cervical  fascia  as  to  require 
separation. 

5.  The  position  and  condition  of  the  lingual  vein  alike  is  at  times 
perplexing.  Usually  it  lies  on  the  hyo-glossus,  occasionally  it  lies 
under  it,  with  its  artery.  Billroth,  who  has  tied  the  lingual  artery 
twenty-seven  times,  tied  the  vein  for  the  artery  in  one  case,  as  was 
verified  post-mortem. 

"  Every  surgeon  knows  the  difficulty  of  tying  the  lingual  artery  in 
old  people ;  the  vessel  lies  so  deep  that  it  is  very  difficult  to  distinguish 
it  from  thick-coated  distended  veins,  especially  when,  owing  to  heart- 
disease — as  in  this  case — the  veins  pulsate.  Never  previously  had  I 
met  with  a  lingual  vein  of  such  thickness."t 

6.  Abnormal  position  of  the  lingual  artery  itself.  This  is  rare,  but 
the  artery  may  lie  higher  than  usual ;  it  may  pierce  the  hyo-glossus ; 
occasionally,  one  lingual  is  minute  or  absent. 

7.  The  sub-maxillary  gland  may  be  unusually  large  and  occupy 
much  of  the^pace  between  the  jaw  and  the  hyoid  bone.^ 

ii.  If  the  vessel  cannot  be  found  on  the  hyo-glossus,  or  if  the  con- 
dition of  soft  parts  is  such,  owing  to  cellulitis,  matting,  enlargement 
of  glands,  as  to  prevent  any  attempt  being  made  here,  the  surgeon 
must  cut  down  upon  the  first  part  either  by  an  incision  similar  to 
the  above  but  less  curved  and  running  from  the  centre  of  the  hyoid 
bone  just  above  the  great  cornu  to  the  anterior  border  of  the  sterno- 
mastoid,  or  by  one  similar  to  that  used  for  ligature  of  the  external 
carotid,  with  its  centre  opposite  to  the  hyoid  bone. 

DifiQculties. 

1.  There  is  no  certain  guide  to  the  artery  here. 

2.  The  artery  itself  is  not  constant  in  position  here,  varieties  occur- 
ring frequently  in  the  height  at  which  it  comes  off  from  the  external 
carotid,  whether  alone,  or  in  common  with  the  facial. 

3.  Large  veins,  e.g.,  the  lingual  and  facial,  will  certainly  be  present. 

LIGATURE  OP  THE  COMMON  CAROTID  (Fig.  87). 

Indications. 

1.  Wounds  of  the  trunk  itself.  Owing  to  the  rapidly  fatal  issue  of 
such  injuries,  the  surgeon  is  not  often  called  upon  to  meet  them.§ 

*  Annals  of  Surgery,  vol.  ii.  No.  11,  p.  359.  f  Clinical  Surgery,  p.  113. 

X  Dr.  Shepherd,  loc.  supra  ciL,  p  361. 

?  These,  in  reality,  rare  wounds  of  the  common  carotid  might,  at  first  sight,  be 
thought  to  be  more  common,  owing  to  the  inaccnrac}'  with  wliich  wounds  of  the  ex- 
ternal carotid  have  been  quoted  as  those  of  the  common  trunk. 


428  OPERATIONS   ON   THE   HEAD   AND   NECK. 

Cases  calling  for  ligature  for  wounds  of  the  trunk  may  be  grouped  as 
follows  :  (a)  For  immediate  hemorrhage ;  (6)  For  secondary  hemor- 
rhage ;  (c)  For  gunshot  injuries. 

(a)  For  Immediate  Hsemorrhage. — Ligature  of  the  common  trunk  is 
here  rarely  called  for,  as  above  stated.  In  civil  practice,  such  cases 
may  occasionally  occur  in  cut-throat.  If  the  surgeon  arrives  in  time, 
he  should  arrest  the  hemorrhage  while  waiting  for  assistance,  by 
thrusting  one  or  more  fingers  into  the  wound  and  making  pressure  on 
the  bleeding-point,  remembering  that  but  slight  force  is  required  if 
the  pressure  is  on  the  right  spot.  If  the  patient  has  to  be  removed 
any  distance,  finger  pressure  must  be  kept  up  or  the  wound  plugged 
with  carbolized  sponge  or  aseptic  gauze,  and  the  head  kept  rigidly 
still.  Pressure  with  a  finger  or  with  a  sponge  on  a  holder  should  be 
kept  upon  the  bleeding  point  while  the  wound  is  enlarged,  and  the 
opening  in  the  carotid  secured  by  ligatures  placed  above  and  below  it. 

Mr.  Butcher,  in  a  case  of  suicidal  cut-throat  implicating  the  common 
carotid,  successfully  ligatured  the  artery  above  and  below,  the  patient 
making  an  excellent  recovery. 

While  the  subject  of  injury  to  the  common  carotid  in  cut-throat  is 
being  alluded  to,  I  may  refer  to  the  following  case  of  Mr.  Guthrie's,* 
which  shows  that  if  the  carotid  is  found  to  be  wounded,  though  not 
opened,  it  is  best  to  apply  ligatures  above  and  below. 

In  a  case  of  attempted  suicide,  the  cut  was  deepest  on  the  left  side, 
having  laid  bare  the  left  carotid  and  wounded  the  internal  jugular. 
"  The  opening  into  the  vein  being  distinct,  I  passed  the  point  of  a 
tenaculum  through  the  edges  made  by  a  cut  into  it,  and,  drawing  them 
together,  passed  a  single  silk  thread  around  so  as  to  close  the  opening 
without  destroying  the  continuity  of  the  vessel.  The  ends  of  the  liga- 
ture were  cut  off  close  to  the  knot.  The  carotid  was  then  clearly  seen 
by  the  side  of  the  vein,  having  a  transverse  mark  or  cut  upon  it,  which 
did  not  appear  to  penetrate  beyond  the  middle  coat ;  and,  after  due 
consideration,  it  was  presumed  that  this  wound  might  heal  without 
requiring  a  ligature  to  be  placed  upon  the  artery.  On  the  eighth  day, 
arterial  hemorrhage  took  place,  and,  on  opening  the  wound,  it  came 
evidently  from  that  part  of  the  carotid  which  had  been  cut.  I  placed 
a  ligature  upon  the  common  carotid  immediately  below  this  opening, 
but  the  flow  of  blood  was  scarcely  diminished  in  quantity  by  it,  in 
consequence  of  the  reflux  from  the  head.  On  attempting  to  apply 
another  ligature  above  the  opening,  I  found,  as  I  had  before  suspected 
from  the  situation  of  the  wound,  that  it  was  immediately  below  the 
division  of  the  common  into  the  external  and  internal  carotids.  The 
hemorrhage  ceased  on  placing  a  ligature  on  the  external  carotid,  and, 

*   Wounds  and  Injuries  of  Arteries,  p.  78. 


LIGATURE   OF   THE   COMMON   CAROTID.  429 

as  the  patient  was  greatly  exhausted,  I  refrained  from  tying  the  other. 
The  bleeding  did  not  return,  but  he  died  the  next  morning  from 
weakness." 

At  the  autopsy  the  internal  jugular  was  found  pervious  and  without 
a  mark  indicating  where  the  ligature  had  been  applied.  The  origin  of 
the  internal  carotid  was  filled  for  about  i  inch  with  a  soft  clot,  the 
wound  in  the  common  carotid  was  exactly  below  its  bifurcation,  and 
Mr.  Guthrie  thought  that  the  ligature  on  the  external  carotid  might 
have  been  sufficient*  if  the  patient  had  lived. 

Mr.  Guthrie  briefly  relates  (loc.  supra  cit,  p.  79)  another  case  in 
which  the  common  carotid  was  wounded  by  a  penknife,  and  the 
haemorrhage  arrested  by  placing  ligatures  on  the  vessel  above  and 
below  the  Avound. 

(b)  For  Secondary  Haemorrhage. — A  remarkable  instance  of  punctured 
wound  of  the  common  carotid  in  which  the  vessel  was  tied  for  second- 
ary haemorrhage  is  thus  recorded  by  Mr.  Durham  :  f 

A  child  aged  nine  was  wounded  with  glass,  owing  to  an  explosion 
of  hydrogen  gas.  When  admitted  into  Guy's  Hospital,  under  the 
care  of  Mr.  Hilton,  the  child  was  cold  and  blanched,  but  the  bleeding, 
which  liad  been  profuse,  had  entirely  ceased.  There  was  a  wound  about 
an  inch  long  "  in  the  left  carotid  region."  On  the  eighth  day  after  the 
accident  haemorrhage  recurred,  and  the  common  carotid  was  tied. 
Nine  days  later,  slight  bleeding  took  place,  but  was  arrested  by  plug- 
ging the  wound  with  sponge.  Repeated  epistaxis  occurred,  which 
weakened  the  child  perceptibly.  The  sloughs  became  very  offensive, 
but  there  was  no  further  bleeding  from  the  wound  for  eighteen  days, 
when  a  considerable  quantity  was  lost.  The  child  gradually  sank,  and 
died  six  weeks  after  the  accident. 

At  the  autopsy  the  common  carotid  was  found  to  have  been  traversed 
by  a  sharp-pointed  fragment.  Behind  the  wounded  vessel  was  an 
abscess  implicating  the  sympathetic.  Mr.  Durham  thinks  that  if  a 
ligature  had  been  applied  on  the  distal  as  well  as  on  the  proximal  aide, 
the  child's  life  would  have  been  saved. 

Another  case  of  secondary  haemorrhage  from  the  common  carotid 
has  recently  been  recorded  by  Mr.  Rivington  ( Trans.  Med.  Chir.  Sac, 
vol.  Ixix.  p.  63).  This  paper,  like  several  others  by  the  same  writer, 
is  replete  with  valuable  information  and  interesting  facts. 

It  is  an  excellent  instance  of  the  way  in  which  the  carotid  may  at 
any  time  be  wounded  from  within,  and  not  from  outside,  by  a  foreign 
body  penetrating  the  pharynx. 

*  This  would  appear  very  doubtful,  owing  to  the  freeness  of  the  collateral  cerebral 
circulation,  and  the  readiness  with  which  a  reflux  current  along  the  internal  carotid 
is  established.     See  the  case  given  at  pp.  4-41,  442, 

t  System  of  Surgery,  vol.  i.  p.  739. 


430  OPERATIONS  ON  THE  HEAD  AND  NECK. 

A  boy,  aged  nine,  six  days  after  swallowing  a  small  plaice-bone,  was 
admitted  into  the  London  Hospital  with  stiffness  and  tenderness  of  the 
neck,  a  small  tender  lump  on  the  left*  side  opposite  to  the  cricoid 
cartilage,  profuse  salivation  and  inabilit}^  to  swallow  solid  food.  On 
the  ninth  and  eleventh  day  haemorrhage  took  place,  on  the  latter 
occasion  to  half  a  pint.  The  following  account  of  the  operation  by 
which  the  injured  vessel  was  found  and  secured  will  be  most  instruc- 
tive to  every  operating  surgeon,  owing  to  the  difficulties  which  pre- 
sented themselves : 

An  incision  was  made  along  the  edge  of  the  sterno-mastoid  for 
several  inches.  The  muscle  was  found  glued  to  the  subjacent  parts 
by  recent  adhesions.  Above  the  anterior  belly  of  the  omo-hyoid  was 
a  dark  patch  about  the  size  of  a  fourpenny-piece,  caused  by  extrava- 
sated  blood  looming  through  the  fascia.  The  fascia  over  the  large 
vessels  being  divided,  a  probe  was  passed  down  into  a  cavity  contain- 
ing clot,  hollowed  out  behind  the  vessels  and  on  the  inner  side.  Owing 
to  the  uniform  discoloration  of  artery,  vein,  nerves,  fascia,  and  areolar 
tissue  by  the  extravasated  blood,  the  structures  met  with,  being  all 
dark  and  equally  stained,  could  scarcely  be  recognized.  The  descendens 
noni  could  not  be  seen,  nor  the  vagus  distinguished,  though  carefully 
looked  for.  More  clots  being  turned  out  from  the  cavity,  in  one  of 
these  the  fish-bone  was  found.  A  gush  of  blood  which  took  place, 
evidently  from  the  distal  end,  was  arrested  partly  by  pressure  and 
partly  ])y  pulling  forward  the  vessels  with  a  blunt  hook.  The  wounded 
vessel  being  found,  a  ligature  was  passed  closely,  as  was  thought, 
around  it,  both  above  and  below  the  seat  of  injury.  Owing  to  the 
danger  of  subjecting  the  patient  to  a  further  loss  of  blood,  there  was 
no  time  to  make  a  prolonged  dissection,  and  it  was  thought  prudent 
to  divide  the  artery  at  the  seat  of  wound  to  make  sure  that  no  branch 
was  given  off  between  the  ligatures.  When  this  was  d.one,  some  nerve 
fibres  were  recognized  on  the  cut  section,  and  the  question  arose 
whether  these  were  the  descendens  noni  or  the  vagus.  As  they  were 
in  front  of  the  vessel,  closely  adherent,  and  apparently  scarcely  nu- 
merous enough  for  the  vagus,  it  Avas  concluded  that  they  belonged  to 
the  descendens  noni,  and  no  attempt  was  made  to  disengage  the  nerve 
or  to  unite  its  extremities.  It  was  proved,  later  on,  that  this  nerve 
was  the  vagus,  which,  instead  of  lying  between  and  behind  the  artery 
and  vein,  took,  or  had  been  pressed  into,  an  unusual  position  in  front 
of  the  artery,  and,  owing  to  the  inflammation  induced  by  the  injury, 
had  become  firmly  adherent  to  the  vessel  for  some  little  distance  above 
and  below  the  aperture  in  the  artery.  Externally  the  nerve  was  stained 

*  Tlie  left  coiumon  carotid  is  more  exposed  to  danger  from  the  passing  of  the 
oesophagus  somewhat  to  this  side. 


LIGATURE   OF   THE    COMMON   CAROTID.  431 

of  the  same  dark  color  as  the  artery,  and  only  in  the  centre,  after  sec- 
tion, were  the  white  nerve-fibres  to  be  recognized.  The  patient  died 
ten  days  after  the  operation,  having  shown  no  evidence  of  ill-effects 
from  the  divided  vagus,  save  perhaps  slight  cough  and  difficulty  in 
swallowing.  Two  gangrenous  abscesses  in  the  left  half  of  the  brain, 
which  were  probably  already  in  progress  prior  to  the  operation,  were 
the  cause  of  death. 

(c)  Division  of  the  common  carotid  by  gunshot  injuries  is  usually  fatal 
at  once,  as  in  two  cases  recorded  in  Circular  No.  3  of  the  War  Depart- 
ment, Washington,  1871. 

2.  Aneurism  of  the  carotid.  Where  an  undoubted  *  aneurism  of  the 
vessel  exists  and  is  increasing  in  spite  of  pressure,t  or  where  this 
cannot  be  made  use  of,  the  artery  should  be  tied,  on  the  cardiac  side 
of  the  aneurism,  if  possible,  or  failing  this  distally. 

The  Mortality  after  Ligature  of  the  Common  Carotid  for 
Aneurism  is  as  yet  high.  Thus  Mr.  Johnson  Smith  {loc.  supra  cit.), 
quoting  from  the  tables  of  M.  Lefort,|  gives  twenty-one  as  fatal  out  of 
forty-seven  cases  of  proximal  ligature.  Mr.  Barwell  §  considers  a  little 
over  25  per  cent,  to  be  the  mortality  in  cases  of  aneurism  proper. 
Whichever  of  these  estimates  is  correct,  in  the  future  the  mortality 
should  be  much  reduced  by  the  advantages  of  aseptic  surgery  and 
modern  ligatures.  The  chief  dangers  to  be  guarded  against  are 
suppuration  of  the  sac  and  hannorrhage,  brain  and  lung  complications, 
and  ha^nnorrhage  from  the  site  of  ligature.  These  are  alluded  to  more 
fully  below,  p.  445. 

The  old  operation  for  carotid  aneurism  is  described  at  p.  442. 

3.  In  aneurism  of  the  innominate  or  aortic  arch.     The  question  of 

*  It  is  well  known  that  this  aneurism  is  diagnosed  more  frequently  than  it  is  really- 
found  to  exist,  owing  to  the  closeness  with  which  some  varicosity  of  the  artery  at  its 
bifurcation,  glandular  and  other  tumors  lying  over  it,  and  in  the  root  of  the  neck,  other 
aneurisms — e.g.,  of  the  innominate,  aorta,  and  subclavian — simulate  a  carotid  aneurism. 
Few  surgeons  will,  I  think,  agree  with  the  statement  of  Mr.  Johnson  Smith  {Diet,  of 
Surg.,  vol.  i.  p.  235)  that  carotid  aneurism  occurs  "  about  as  often  as  subclavian  aneurism, 
and  with  greater  frequency  than  aneurism  of  the  axillary  artery." 

t  This  may  be  applied  to  the  artery  or  the  sac,  or  both.  In  the  former  case  the 
artery  should  be  compressed  above  the  transverse  process  of  the  sixth  cervical  vertebra, 
to  avoid  making  pressure  on  the  vertebral  at  the  same  time.  If  pain,  vertigo,  sickness, 
etc.,  prevent  a  fair  trial  of  digital  pressure,  an  anjesthetic  may  be  tried,  but,  as  Mr.  Bar- 
well  point.s  out  (Encycl.  of  Surg.,  vol.  iii.  p.  498),  there  may  be  much  difficulty  in  de- 
ciding how  far  the  syncope,  etc.,  which  may  be  present  are  due  to  the  anaesthetic  or  to  the 
pressure.  Another  means  of  keeping  up  pressure  on  the  common  carotid  is  that  sug- 
gested by  Rouge,  in  which  the  sterno-mastoid  being  relaxed  the  surgeon  insinuates  his 
fingers  behind  one  border,  and  his  thumb  behind  the  other  border,  of  the  muscle,  and 
thus  compresses  the  artery  between  them. 

J  Gaz.  Hebd  ,  18Q4:  and  18G8. 

§  Loc  supra  cit.,  p.  502. 


482  OPERATIONS    ON   THE    HEAD    AND    NECK. 

the  aclvisabilit}'-  of  ligaturing  the  carotid  either  together  with  the  sub- 
clavian, or  alone,  especially  in  the  case  of  the  left  common  carotid,  is 
considered  on  a  subsequent  page. 

4.  In  orbital  aneurism,  where  the  symptoms  are  becoming  aggra- 
vated, or  where  pressure  has  failed,  or  where  it  cannot  be  endured,  even 
intermittently,  for  a  few  minutes  only  at  a  time,  and  where  galvano- 
puncture  and  injection  of  coagulating  fluids  are  set  aside  owing  to 
their  uncertainty  and  riskiness.* 

Of  the  fifty-three  cases  (Rivington,  he.  supra  cit.),  including  twenty- 
one  idiopathic  and  thirty-two  traumatic,  in  which  the  common  carotid 
was  tied,  thirteen  of  the  former  were  cured  and  seventeen  of  the  latter. 
The  above  writer,  speaking  of  this  mode  of  treatment,  says  it  is  "  at 
present  the  most  successful  and  satisfactory  means  of  trea.ting  orbital 
aneurism.  It  should  not  be  practiced  on  patients  advanced  in  years, 
or  on  those  Avith  heart  disease,  or  evident  atheromatous  degeneration 
of  arteries." 

5.  In  aneurism  of  the  external  or  internal  carotid.  These  are  very 
rare.  Two  cases  of  aneurism  of  the  former  vessel  have  been  recently 
published.  Mr.  Morris  f  recorded  one  in  which,  after  failure  of  liga- 
ture of  the  common  carotid,  the  old  operation  of  incising  the  sac  was 
performed,  and  ligatures  placed  on  the  facial  and  lingual  arteries,  and 
upon  the  main  trunk  of  the  external  carotid  above  the  sac,  with  ulti- 
mate recovery. 

The  second  case  was  published  by  Mr.  Heath  l  in  order  to  prove 
that  ligature  of  the  common  carotid  alone  is  sufficient  to  cure  some 
cases  of  aneurism  of  the  external  carotid. 

The  occurrence  of  aneurism  here  in  a  woman,  aged  twenty-three, 
was  accounted  for  by  the  state  of  the  cardiac  valves  and  the  liability 
for  embolism  to  occur  in  consequence  of  detachment  of  a  vegetation. 
There  was  a  smooth,  round,  pulsating  swelling  just  below  the  right 
mastoid  process,  reaching  down  to  about  the  level  of  the  upper  border 
of  the  thyroid  cartilage.  It  had  the  size  and  shape  of  half  a  small 
orange.  The  right  tonsil  was  somewhat  pushed  inwards,  the  right 
temporal  pulse  was  markedly  weaker  than  the  left,  and  the  tongue 
deviated  much  to  the  right,  the  right  half  being  a  good  deal  wasted. 
The  common  carotid  was  tied  and  the  wound  healed,  pulsation  in  the 
aneurism  had  stopped  on  the  tenth  day,  and  on  the  eighteenth  the  sac 

*  Mr.  Rivington  [Diet,  of  Surg.,  vol.  ii.  p.  131)  speaks  thus  of  injection  :  "  It  is  more 
painful  than  ligature,  and  probably  involves  more  risk  to  vision,  as  it  may  set  up  in- 
flammatory mischief  in  the  loose  areolar  tissue  around  the  veins,  which  may  spread  to 
the  cornea.  It  may  also  effect  so  much  coagulation  as  to  interfere  with  the  requisite 
supply  of  blood  for  the  maintenance  of  the  ocular  tissues." 

f  il/ed.  Chir.  Trans.,  vol.  Ixiv.  p.  1. 

X  Ibid.,  vol.  Ixxxiii.  p.  69. 


LIGATURE    OF    THE   COMMON    CAROTID.  433 

"was  smaller  and  quite  hard.  All  seemed  to  be  doing  well  till  the 
thirty-third  day  after  the  operation,  when  loss  of  speech  occurred 
somewhat  suddenly,  followed  by  right  hemiplegia,  and  death  on  the 
thirty-fifth  day,  this  being  brought  about  by  cerebral  embolism  tak- 
ing place  through  the  left  carotid,  the  aneurism  being  solidified 
throughout. 

Aneurism  of  the  internal  carotid  is  equally  rare. 

The  following  is  a  brief  abstract  of  such  a  case  *  in  which  the  com- 
mon and  external  carotids  were  tied,  together  with  the  superior  thy- 
roids, successfully. 

The  internal  trunk  was  affected  with  atheroma  to  such  an  extent 
that  the  ligature  could  not  be  applied  to  this  vessel.  The  operation 
was  done  July  24,  1883.  The  tumor  rapidly  diminished  in  size,  the 
patient  leaving  the  hospital  on  the  twenty-ninth  day  after  the  opera- 
tion.    She  is  now  living  and  well. 

6.  In  hjemorrhage  caused  by  ulceration  of  the  throat  after  scarlet 
fever. 

This  is  a  rare  but  most  dangerous  complication  of  ulceration  of  the 
throat,  and  is  usually  brought  about  either  by  sloughing  of  the  soft 
parts,  or,  as  in  the  case  mentioned  below,  by  the  opening  of  an  artery 
or  vein  into  an  abscess  cavity. 

My  old  friend  Dr.  IMahomed  communicated  a  case  to  the  Clinical 
Society  (Trans.,  vol.  xvi.  p.  21)  in  which  this  complication  occurred  in 
a  patient  aged  21.  Secondary  sore  throat,  after  an  ordinary  convales- 
cence, was  noticed  on  the  54th  day,  with  much  swelling  on  the  left 
side  of  the  neck,  followed  by  severe  bleeding  (to  40  ounces)  from  the 
mouth  on  the  58th  day.  The  left  common  carotid  was  tied  by  Mr. 
Pepper  on  the  59th  day.  Five  and  a  half  ounces  of  pus  were  brought 
up  soon  after  the  operation,  and  the  swelling  of  neck  and  pharynx 
subsided,  a  good  recovery  ultimately  taking  place. 

The  common  carotid  was  selected  for  ligature  in  preference  to  the 
external,  since  it  allowed  the  operation  to  be  performed  quite  clear  of 
the  infiltrated  tissues,  and  thus  conferred  a  greater  immunity  from 
secondary  haemorrhage.  Moreover,  had  the  original  bleeding  have 
come  from  the  ascending  pharyngeal,  ligature  of  the  external  carotid 
might  have  failed  to  arrest  it,  as  the  place  of  origin  of  the  former  ves- 
sel is  variable. 

The  next  series  of  cases,  7  to  11,  rather  call  for  ligature  of  the  ex- 
ternal carotid  than  of  the  common  trunk.  With  reference  to  them  it 
must  be  remembered,  that  ligature  of  the  common  carotid  must  be 
resorted  to,  not,  as  has  too  often  been  the  case,  on  account  of  the 
greater  facility  with  which  this  vessel  can  be  tied,  but  only  when  the 

*  Dr.  Wyeth,  Annals  of  Sargei-y,  August,  1887,  p.  114. 
28 


434  OPERATIONS  ON  THE  HEAD  AND  NECK. 

condition  of  the  parts  does  not,  either  primarily,  from  an  anatomical 
point  of  view,  or,  later  on,  after  secondary  haimorrhage,  admit  of  tying 
the  external  carotid  itself.* 

7.  Incised  or  punctured  wound  near  the  angle  of  the  jaw. 

In  these  cases,  as  in  those  below,  a  correct  diagnosis  as  to  the  ves- 
sel or  vessels  injured  is  by  no  means  easy  when  a  sharp  weapon  has 
passed  obliquely  and  deeply  behind  the  angle  of  the  jaw.  By  such  a 
wound  either  the  external  or  the  internal  carotid  or  some  branches  of 
the  former  may  be  laid  open.  A  careful  dissection  can  alone  clear  up 
the  source  of  the  bleeding,  and  whenever  it  is  possible  this  should  be 
resorted  to ;  where  the  circumstances  do  not  admit  of  this,  the  surgeon, 
relying  upon  the  extreme  rarity  of  injury  to  the  internal  carotid  from 
its  protected  position,!  will  be  abundantly  justified  in  tying  the  ex- 
ternal carotid.  Ligature  of  the  common  trunk  is  less  reliable,  though) 
if  resorted  to,  on  account  of  its  simplicity,  it  may  be  defended  by 
cases  like  those  briefly  alluded  to  by  Mr.  Le  Gros  Clark,:]:  in  which  he 
successfully  tied  the  common  carotid  for  profuse  arterial  hemorrhage 
due  to  stabs  near  the  angle  of  the  jaw.  "  The  injury  was  inflicted  in 
the  same  way,  and  with  the  same  form  of  instrument,  in  both 
instances — a  pointed  table-knife  was  plunged  downwards  and  inwards 
behind  the  angle  of  the  jaw.  The  bleeding  was,  in  each  case,  con- 
trolled only  by  direct  pressure  with  the  fingers  in  the  wound ;  and 
whilst  this  pressure  was  maintained  I  tied  the  artery.  Not  an 
untoward  symptom  accompanied  or  followed  either  of  these  opera- 
tions." 

On  the  other  hand,  cases  of  penetrating  wounds  near  the  angle  of 
the  jaw,  ending  fatally  from  ha3morrhage  after  ligature  of  the  common 
carotid,  will  be  found  published  by  Mr.  Travers§  and  Mr.  Partridge.] | 

8.  Punctured  wounds  through  the  mouth. 

Here,  too,  the  common  carotid  has  been  tied  in  some  cases  success- 
fully, while  in  others  this  step  has  been  followed  by  repeated  haemor- 
rhages and  death. 

The  following  case  may  be  quoted  as  an  instance  of  the  former  re- 
sult: A  child  fell  while  holding  the  sharp  end  of  a  parasol  in  his 
mouth,  the  point  being  thrust  forcibly  to  the  back  of  the  fauces  and 


*  In  some  of  these  cases  the  hsemorrhage  may  be  arrested,  and  the  dangers  of  tying 
the  common  carotid  avoided  by  the  temporary  closure  of  tl\is  vessel  by  a  loop  of  stout 
catgut,  applied  as  at  pp.  441,  448. 

f  Mr.  Cripps  {3fed.  Chir.  Trans.,  vol.  Ixi.  p.  235)  shows  that,  out  of  eighteen  cases 
in  which  the  bleeding  vessel  was  identified,  the  internal  carotid  was  found  only  to  have 
been  wounded  twice  alone,  and  once  in  conjunction  with  the  external. 

X  Lectures  on  Surgical  Diagnosis,  Shock,  and  Visceral  Lesions,  p.  222. 

§  Med.  Chir.  Trans.,  1827,  p.  165. 

II  Lancet,  1861,  vol.  i.  p.  659. 


LIGATURE   OF   THE   COMMOIT   CAROTID.  435 

very  nearly  coming  through  the  skin  at  the  side  of  the  neck.  Con- 
siderable haemorrhage  occurred  at  once,  and  also  about  a  week  later. 
Ten  days  later  a  gush  of  arterial  blood  followed  on  coughing.  The 
common  carotid  artery  was  tied  and  the  case  ended  successfully.* 

On  the  other  hand,  cases  ending  fatally  after  ligature  of  the  common 
carotid  for  hfemorrhage  after  punctured  wounds  of  the  mouth,  will 
be  found  recorded  by  Mr.  Vincent,t  Mr.  Arnott,J  and  Mr.  Morrant 
Baker.§ 

9.  HiTemorrhage  from  carcinoma  of  the  mouth,  e.g.,  tongue  or 
fauces. 

This  subject  is  discussed  at  p.  340.  It  would  be  better  surgery  to 
tie  the  lingual  in  the  case  of  tongue  cancer,  or,  if  the  growth  be  farther 
back,  to  tie  the  external  carotid  and  ascending  pharyngeal,  and  only, 
if  this  be  found  imj^ossible,  to  ligature  the  common  trunk, 

10.  Hjemorrhage  after  removal  or  incision  of  tonsils,  or  from  abscess 
about  a  tonsil. 

These  cases  are  infrequent,  but  when  the}^  do  occur,  are,  in  many 
cases,  most  dangerous.  The  sources  of  the  haemorrhage  are  very 
numerous — viz.,  (1)  One  of  the  tonsillar  arteries.  (2)  The  tonsillar 
venous  plexus.  (3)  The  ascending  pharyngeal.  (4)  The  internal 
carotid.  Haemorrhage  from  the  last  two  is  much  more  likely  to  occur 
in  suppuration  in  or  around  the  tonsil,  than  in  wounds  inflicted 
during  operations  on  it. 

The  following  is  a  good  instance  ||  of  a  tonsillar  abscess  proving 
fatal  from  haemorrhage.  A  man,  aged  39,  was  admitted  with  severe 
tonsillar  abscess,  which  soon  burst  with  the  escape  of  a  little  blood. 
About  16  oz.  were  lost  on  the  third  day,  bleeding  again  recurring  on 
the  fourth  and  fifth.  The  left  common  carotid  Avas  now  tied  ;  thirty 
hours  afterwards  22  oz.  were  lost,  and  the  patient  died. 

There  was  an  abscess  cavity  around  the  left  tonsil  which  communi- 
cated with  the  left  carotid  by  an  opening  the  size  of  the  little  finger 
nail. 

*  The  case  was  under  the  care  of  Mr.  Johnson  at  St.  George's  Hospital.  It  is 
quoted  by  Mr.  Durham,  Syst.  of  Surg.,  vol.  i.  p.  745. 

t  Med.  Chir.  Trans.,  vol.  xxix.  p.  38.  In  this  case  the  bifurcation  of  the  right  com- 
mon carotid  had  been  punctured  by  a  bit  of  broken  tobacco-pipe  from  within  the 
mouth.  Sloughy  cellulitis  set  in,  and  hsemorrhage  took  place  from  the  mouth  a  week 
after  the  accident.  This  was  arrested  by  ligature  of  the  common  carotid,  but  recurred 
on  the  second,  and  again,  fatally,  on  the  fifth  day  after  the  operation.  Mr.  Vincent 
points  out  that  if  the  bit  of  tobacco-pipe  had  been  discovered  and  removed,  fatal  haem- 
orrhage must  have  followed  instantly,  as  the  artery  was  not  only  wounded,  but  plugged 
by  the  foreign  body. 

X  Lancet,  1864,  vol.  i.  p.  135. 

I  St.  Barthol.  Hosp.  Reports,  1876,  p.  163. 

II  Mr.  Pitts,  St.  Thomas's  Hosp.  Reports,  vol.  xii.  p.  131. 


436  OPERATIONS   ON   THE   HEAD   AND   NECK. 

Mr.  Morrant  Baker  has  recorded  the  following  case  of  suppuration 
around  the  tonsil  dating  to  an  injury.  Here  the  vessel  injured  was 
the  ascending  pharyngeal,  but  too  short  a  time  elapsed  between  the 
ligature  of  the  common  carotid  and  the  death  of  the  patient  to  say 
whether  the  operation  would  have  been  successful. 

A  man,  aged  23,  was  admitted  with  symptoms  of  acute  tonsillitis, 
the  parts  being  tense,  elastic,  and  prominent  at  one  spot.  A  puncture 
was  only  followed  by  the  escape  of  blood.  The  patient  now  gave  a 
history  of  having  fallen  two  days  before,  when  drunk,  and  having 
grazed  his  throat  with  a  clay  pipe;  this  had  been  followed  by  very 
little  bleeding.  Some  improvement  seemed  at  first  to  take  place,  but 
the  temperature  went  up  to  105°,  and  arterial  haemorrhage  occurred 
on  the  third  day  after  admission.  A  probe  passed  through  the  punct- 
ure showed  that  a  considerable  cavity  existed,  this  was  plugged  wdth 
lint  soaked  in  tr.  ferri  perchlor.  The  next  day  haemorrhage  recurred 
to  half  a  pint ;  when  ether  was  given  the  bleeding  again  came  on, 
nearly  suffocating  the  patient.  On  exploring  the  cavity  with  a  finger- 
tip, a  bit  of  clay  pipe  was  withdrawn  ;  the  cavity  was  again  plugged 
and  the  common  carotid  tied.  The  patient  died,  without  rallying, 
three  hours  later.  A  wound  was  found  in  the  ascending  pharyngeal 
artery. 

Given  a  case  of  haemorrhage  from  the  tonsil  (whether  from  a  wound 
or  an  abscess)  which  resists  other  treatment,  including  well-applied 
pressure  kept  up  with  a  padded  stick  inside  the  mouth  and  a  finger 
behind  the  angle  of  the  jaw,  the  surgeon  should  tie  the  external  carotid 
as  low  down  as  possible,  placing  a  ligature  on  the  ascending  pharyn- 
geal as  well,  if  this  vessel  can  be  identified.  If  the  bleeding  is  from 
one  of  the  tonsillar  vessels  it  would  be  thus  arrested,  but  in  case  the 
ascending  pharyngeal  is  not  secured,  or  the  bleeding  comes  from  the 
internal  carotid,  a  loop  of  stout  chromic  gut  should  be  placed  as  well 
under  the  top  of  the  common  carotid  in  the  manner  recommended  by 
Mr.  Rivington  and  Mr,  Reeves  (pp.  441,  448).* 

11.  Haemorrhage  after  operations  on  neck  or  jaw.  Haemorrhage 
secondary  to  gunshot  injuries. 

In  both  these  cases  the  parts  may  be  so  altered  that  it  is  quite 
impossible  to  find  the  bleeding  point,  and  the  soft  parts  may  be  so 
damaged,  matted  together,  etc.,  that  the  surgeon  may  be  driven  to  tie 
the  common  carotid,  and  trust  to  this  and  to  plugging  the  wound, 
rendered  as  aseptic  as  possible  with  sal  alembroth  or  iodoform  gauze,t 
and  sponge-pressure  over  all. 


*  Every  care  should  be  taken  throughout  to  keep  the  wound  in  the  tonsil  as  aseptic 
as  possible.  As  bearing  on  the  use  of  iron  perchloride  as  a  styptic,  see  some  remarks 
at  p.  423,  foot-note. 

■f  These  may  first  be  soaked  in  turpentine  (p.  422). 


LIGATURE    OF   THE    COMMON    CAROTID.  437 

12.  To  arrest  the  growth  of  aneurism  by  anastomosis  on  the  side  of 
face,  head,  and  neck. 

The  treatment  of  this  condition  is  discussed  at  p.  449.  It  will  be 
shown  there  that  ligature  of  the  external  carotid  cannot  usually  be 
looked  upon  as  sufficient  without  other  measures,  owing  to  the  free 
anastomosis  between  the  branches  of  the  opposite  vessels.  Still  less 
is  ligature  of  the  common  carotid  likely  to  be  successful,  and  this  step 
should  only  be  resorted  to  when  ligature  of  the  external  carotid  is 
impossible  from  the  disease  extending  too  low  down,  when,  from  its 
creeping  towards  the  orbit  or  at  the  back  of  the  upper  jaw,  it  is  prob- 
able that  there  is  a  free  anastomosis  between  the  branches  of  the 
external  and  internal  carotid  through  the  ophthalmic,  or  when  the 
ascending  pharyngeal  is  sure  to  be  involved,  but  this  branch  cannot 
be  separately  ligatured. 

13.  To  arrest  the  growth  of  malignant  tumors  of  the  jaws  which 
cannot  be  oj^erated  on,  or  which  are  returning  after  operation. 

This  operation,  first  performed  by  Mott,  is  a  very  proper  one  in 
cases  of  malignant  disease  of  the  antrum,  nose,  etc.,  where  the  growth 
cannot  otherwise  be  attacked  and  is  growing  very  rapidly,  causing 
frequent  bleeding,  intense  pain,  and  threatening  to  interfere  with 
deglutition  and  respiration. 

The  surgeon  must  be  prepared  for  a  good  deal  of  sloughing,  foetor, 
etc.,  as  well  as  shrinking  in  very  vascular  growths  which  have  begun 
to  fungate. 

In  this  case,  also,  it  will  be  a  question  as  to  whether  it  is  wiser  to 
ligature  both  external  carotids  or  the  common  carotid.  The  sugges- 
tions made  at  p.  451  may  help  here.  If  the  common  carotid  is  tied, 
the  opposite  external  carotid  should  be  ligatured  also,  either  at  the 
same  time  or  very  shortly  after,  owing  to  the  free  anastomoses,  which 
will  bring  blood  over  from  the  opposite  side. 

In  any  case  it  should  be  an  operation  to  be  performed  at  the 
patient's  request  after  the  matter  has  been  explained  to  him,  in  the 
hope  that  its  performance  may  lead  to  relief  from  the  urgent  local 
symptoms  of  the  growth,  and  that  life  may  be  brought  to  a  close,  after 
an  interval  of  relief,  by  increasing,  but  less  painful,  asthenia. 

Line. — From  the  sterno-clavicular  articulation  to  a  point  midway 
between  the  angle  of  the  jaw  and  the  mastoid  process. 

Guide. — The  above  line,  and  the  inner  edge  of  the  sterno-mastoid, 

Kelations. — The  common  carotids,  as  far  as  their  relations  in  the 
neck  go,  extend  from  the  sterno-clavicular  articulation  to  the  upper 
border  of  the  thyroid  cartilage  along  a  line  from  the  above  joint  to  a 
point  midway  between  the  ear  and  the  mastoid  process. 


438  opeeations  on  the  head  and  neck. 

In  Front. 

Skin ;  fascise ;  platysma  ;  superficial  branches  of  trans- 
verse cervical  and  anterior  jugular. 

Sterno-mastoid,  sterno-hyoid,  sterno-thyroid,  omo-hyoid, 
sterno-mastoid  artery. 

Superior  and  middle  thyroid  veins. 

Descendens  noni. 

Anterior  jugular  vein  (below). 

Outside.  Inside. 

Internal  jugular  (closer  on  Pharynx. 

left  side).  Larynx. 

Trachea. 

Thyroid  gland  and  vessels. 
Recurrent  laryngeal. 
Common  carotid. 

Behind. 
*■    Rectus  capitis  anticus  major. 
Longus  colli. 
Sympathetic. 

Inferior  thyroid  artery  and  recurrent  laryngeal. 
Vagus. 

Operation. — Two  sites  are  usually  described,  according  as  the 
vessel  is  tied  above  or  below  the  omo-hyoid. 

A.  Above  the  Omo-hyoid  (Fig.  87). — Also  known  as  the  seat  of 
election,  owing  to  the  greater  facility  with  which  this  operation  is 
usually  performed. 

The  parts  being  cleansed  and  shaved  if  needful,  the  shoulders  are 
sufficiently  raised,  and  the  chin  at  first  drawn  a  little  upwards,  while 
the  head  is  turned  to  the  opposite  side,*  so  as  to  define  the  anterior 
border  of  the  sterno-mastoid.f  The  surgeon,  standing  usually  on  the 
same  side,  makes  an  incision  about  3  inches  long,  with  its  centre  op- 
posite to  the  cricoid  cartilage,  in  the  line  of  the  artery,  through  the 
skin,  platysma,  and  fasciae,  exposing  the  anterior  border  of  the  sterno- 

*  Turning  the  head  strongly  to  the  opposite  side  should  be  avoided,  as  it  brings  the 
muscle  over  the  artery.  Mr.  Barwell  {Encyd.  Surg.,  vol.  iii.  p.  498)  gives  the  following 
practical  hint:  "In  certain  aneurismal  cases  (aortic  and  innominate)  the  etherized 
patient  cannot  breathe  while  his  head  is  thrown  back  ;  the  anaesthetizer  is  obliged  to 
insist  on  bending  it  forward,  and  the  operator  has  to  get  at  the  vessel  under  very  try- 
ing circumstances,  since  in  that  posture  it  lies  much  deeper,  and  the  ramus  of  the  jaw 
is  terribly  in  the  way." 

t  Not  always  easy  on  the  dead  subject,  or  when  the  parts  are  infiltrated,  as  in  Mr. 
Vincent's  case  (foot-note,  p.  435). 


LIGATURE   OF   THE    COMMON   CAROTID. 


439 


mastoid.  Any  superficial  veins  are  now  drawn  aside,  or  tied  before 
division  with  double  catgut  ligatures.  The  deep  fascia  at  the  anterior 
border  of  the  sterno-mastoid  is  now  divided,  and  the  cellular  tissue 
beneath  opened  up,  usually  bringing  into  view  the  upper  border  of 


Fig.  87. 


In  the  ligature  of  the  common  carotid  the  only  structures  seen  are  the  omo-hyoid,  crossing 
the  vessel  below,  and  the  superior  thyroid  vein  above.  Externally  is  a  portion  of  the  internal 
jugular,  and  more  superficially  the  sterno-mastoid.  The  deep  fascia  is  seen  in  the  upper  and 
lower  angles  of  the  wound. 

In  the  ligature  of  the  subclavian,  the  sterno-mastoid  and  the  trapezius  are  seen  in  the  angles 
of  the  wound.  Above  the  vessel  lie  the  cords  of  the  plexus,  crossed  by  two  veins,  probably  the 
transverse  cervical  and  the  posterior  scapular,  coursing  inwards  to  join  the  external  jugular, 
which  is  seen  at  the  inner  part  of  the  wound.  Below  the  subclavian  artery  is  seen  a  portion  (too 
much  is  shown)  of  the  supra-scapular  artery. 

The  angular  incision  shows  that  for  ligature  of  the  innominate,  the  first  part  of  the  subclavian, 
and,  in  cases  of  difficulty,  the  first  part  of  the  carotid. 

the  omo-hyoid,  which,  if  in  the  way,  is  drawn  down  with  a  blunt 
hook,  or  divided.  The  edge  of  the  sterno-mastoid  is  now  drawn  out- 
wards, and  the  pulsations  of  the  artery  felt  for  just  below  the  omo- 
hyoid.* In  clearing  the  tissues  which  remain  over  the  vessel, 
troublesome  haemorrhage  may  arise  from  the  superior  and  middle 
thyroid  veins,  especially  if  the  respiration  is  embarrassed  ;  more 
rarely  the  sterno-mastoid  artery  is  cut,  and  requires  a  ligature.  The 
sheath  is  next  exposed,  and  opened  well  to  the  inner  side,  avoiding 


*  This  muscle  should  be  drawn  downwards,  or  divided  if  needful. 


440  OPERATIONS    ON    THE    HEAD    AND    NECK. 

the  descendens  noni,  which  usually  lies  to  the  front  and  outer  side  of 
the  sheath* 

Other  difficulties  which  may  be  now  met  with  are  an  enlarged  thy- 
roid lobe  overhanging  the  artery,  or  overlap])ing  of  it  by  the  internal 
jugular  when  much  distended.  The  coats  of  this  vessel  are  so  thin 
that,  if  it  be  much  swollen,  it  is  easily  punctured,  the  result  being  that 
the  wound  is  flooded  with  blood.  It  is  best  avoided  by  opening  the 
sheath  well  to  the  inner  side,  but,  if  it  still  give  trouble,  it  should  be 
drawn  aside  with  a  blunt  hook,  or  pressure  should  be  made  on  it  by 
an  assistant  in  the  upper  angle  of  the  wound.  If  it  should  be  opened, 
firm  pressure  should  be  made  on  this  spot  with  a  sj^onge-holder,  and 
the  artery  tied  at  a  fresh  place  above  or  below.  As  soon  as  the  liga- 
ture is  tightened  the  haemorrhage  will  cease,  and  firmly  applied  press- 
ure outside  the  wound  for  forty-eight  hours  will  suffice  to  prevent 
any  recurrence.  If,  after  wounding  the  vein,  attempts  are  continued 
to  tie  the  artery  at  the  same  place,  the  wound  in  the  vein  is  almost 
certain  to  be  made  larger.  Another  method  is  to  pinch  up  the  wound 
in  the  vein  and  tie  up  the  opening  (if  small)  with  fine  carbolized  silk 
or  chromic  catgut. 

The  sheath  having  been  opened  well  to  the  inner  side  with  a  careful 
nick  of  the  knife,  the  artery  is  now  cautiously  and  sufficiently  cleaned, 
the  inner  edge  of  the  sheath  being  held  with  forceps  while  this  side  of 
the  vessel  is  cleaned,  and  then  the  outer  in  the  same  way,  and,  finally, 
the  posterior  aspect,  the  point  of  the  director  being  kept  most  scrupu- 
lously in  contact  with  the  vessel  here.f  The  needle  is  then  passed 
from  without  inwards,  being  kept  most  carefully  free  from  the  artery, 
especially  behind,  so  as  to  avoid  including  the  vagus. 

In  this,  as  in  every  other  artery  whose  relations  are  important,  the 
fewer  of  these  relations  that  the  surgeon  sees  the  more  masterly  and 
successful  will  his  operation  be. 

In  a  deeply  lying  artery,  in  addition  to  relaxing  the  parts  by  flexing 
forward  the  head  and  depressing  the  chin,  the  sterno-mastoid  must  be 
drawn  outwards  and  the  larynx  inwards  with  retractors,  while  the 
omo-hyoid  is  drawn  downwards  with  a  blunt  hook,  or  divided.  The 
pulsation  of  the  artery  is  then  felt  for,  or,  where  this  is  feeble  or  absent, 
the  rolling  of  the  artery  as  a  flat  cord  under  the  finger  is  made  out. 

B.  Ligature  below  the  Omo-hyoid. — Here  the  artery  lies  much 
deeper,  and  has  the  recurrent  laryngeal  nerve  behind  it ;  on  the  left 
side,  the  internal  jugular  vein  lies  very  close  to  the  artery ;  on  the 
right,  there  is  a  distinct  interval  between  the  two  vessels. 

The  patient's  head  and  the  operator  being  in  the  same  position  as  at 

*  The  position  of  this  nerve  is,  however,  very  irregular. 

t  Opening  the  sheath  on  the  inner  side  and  cleaning  the  vessel  properly  are  the 
two  best  safeguards  against  accidents. 


LIGATURE    OF    THE    COMMON    CAROTID.  441 

p.  438,  an  incision  3  inches  long  is  made  in  the  line  of  the  artery  from 
below  the  cricoid  cartilage  to  just  above  the  sterno-clavicular  joint, 
exposing,  as  before,  the  anterior  edge  of  the  sterno-mastoid.  This  is 
drawn  outwards,  and,  if  needful,  divided  or  detached  below  by  making 
a  short  incision  outwards  along  the  clavicle.  In  this  case  the  anterior 
jugular  vein  must  be  carefully  looked  for  as  it  passes  outwards  in  the 
root  of  tlie  neck  under  the  sterno-mastoid.  The  depressors  of  the 
hyoid  bone  next  come  into  view ;  of  these  the  sterno-hyoid  overlying 
the  broader  sterno-thyroid  is  certain  to  be  seen.  If  the  omo-hyoid  is 
coming  up  at  this  level,  it  lies  external  to  the  others.  In  such  case  it 
is  to  be  drawn  out  while  the  other  two  are  pulled  inwards,  any  of  the 
three  being  divided,  on  a  director,  if  needful.  At  this  stage  one  or 
more  of  the  inferior  th3'roid  veins  may  come  into  view,  much  swollen. 
The  pulsation  of  the  artery  being  felt  for,  or  the  flattened  artery  felt 
slipping  beneath  the  finger  when  pressed  upon,  the  sheath  is  to  be 
opened  well  to  the  inner  side,  retractors  usually  being  required  at  this 
stage.  Care  must  be  taken  of  the  internal  jugular,  especially  on  the 
left  side,  as,  if  distended,  it  may  conceal  the  artery  (p.  440). 

When  the  carotid  is  sufficiently  cleaned,  the  needle  is  jDassed  from 
without  inwards,  avoiding  the  recurrent  laryngeal  nerve  behind  by 
keeping  very  close  to  the  artery. 

Temporary  Ligature  of  the  Carotid. — Mr.  Rivington  (p.  448) 
and  Mr.  Treves*  have  drawn  attention  to  this  method,  believing  that 
the  ligature  of  main  arteries  is  resorted  to  too  often,  as  there  is  suffi- 
cient evidence  to  show  that  in  most  cases  it  is  only  temporary  arrest 
of  the  current  that  is  required. 

This  method  should  certainly  receive  a  further  trial,  on  account  of 
the  risks  of  cerebral  mischief  after  ligature  of  the  carotid,  and  also 
because,  as  Mr.  Treves  says,  pressure  upon  the  carotid  cannot  be  suc- 
cessfully maintained  for  a  serviceable  length  of  time. 

The  artery  being  exposed  in  the  ordinary  way,  a  thick  piece  of  soft 
catgut  is  passed  round  it  and  tied  in  a  very  loose  loop.  By  pulling 
on  the  loop,  the  blood-current  is  at  once  arrested,  and  restored  when 
the  tension  is  relaxed. 

The  following  are  abstracts  of  the  four  cases  given  by  Mi*.  Treves : 

1.  Probable  Wound  of  Superior  Thyroid  Artery. — A  young  man  was 
admitted  with  a  deep,  profusely  bleeding  wound  about  the  level  of 
the  great  cornu  of  the  hyoid.  A  fragment  of  glass  driven  in  by  a 
bursting  soda-water  bottle  had  been  removed.  The  patient  was 
blanched  and  almost  insensible.  It  being  "  obviously  useless  to 
attempt  to  find  the  bleeding  point  while  blood  was  welling  up  from 
60  deep  a  wound,"  Mr.  Treves  placed  a  temporary  ligature  round  the 

*  Lancet,  January  21,  1888,  p.  111. 


442  OPERATIONS  ON  THE  HEAD  AND  NECK. 

common  carotid.  Traction  on  this  arrested  all  bleeding,  and  was 
maintained  for  half  an  hour.  On  relaxing  the  catgut,  no  haBmorrhage 
occurred.  The  loop  was  left  in  situ  for  four  days,  and  then  removed. 
The  bleeding  was  supposed  to  have  come  from  the  superior  thyroid. 

2.  Haemorrhage  from  Internal  Carotid. — A  child,  aged  three,  had 
profuse  haemorrhage  from  the  right  ear,  and  vomited  blood.  This 
recurred,  and  the  right  common  carotid  was  ligatured,  and  the  bleeding 
ceased.  The  next  day  the  same  haemorrhage  recurred,  having  evi- 
dently been  brought  round  by  the  left  carotid.  As  there  is  no  case  on 
record  of  recovery  after  ligature  of  both  common  carotids  when  the 
interval  between  the  occlusion  of  the  two  vessels  was  less  than  some 
weeks,  Mr.  Treves  simply  placed  a  loop  of  catgut  round  the  left 
carotid,  and  had  traction  made  on  it.  The  child  never  bled  again,  but 
sank  exhausted  six  days  after  the  second  operation. 

3.  Haemorrhage,  probably  from  External  Carotid,  after  Impalement 
with  a  Spike. — A  man,  aged  forty -one,  fell  26  feet  upon  a  railing  spike, 
which,  entering  just  in  front  of  the  left  ear,  j^assed  through  the  upper 
jaws,  and  entered  the  mouth  through  the  hard  palate  on  the  right  side. 
After  removal  of  the  spike,  blood  welled  up  freely  from  the  wounds 
and  nose.  Traction  made  on  a  catgut  loo-p  passed  round  the  common 
carotid  arrested  this.  A  weak  pulse  could  be  felt  in  the  temporal  on 
the  fourth  day,  and  on  the  seventh  the  loop  was  removed.  The  case 
did  well.     It  is  not  stated  how  long  traction  was  maintained. 

4.  Haemorrhage  during  an  Operation. — In  this  case  the  loop  was 
placed  around  the  artery  prior  to  removing  a  large  malignant  tumor 
of  the  neck.  Very  free  bleeding  occurred  during  the  operation,  but 
was  always  checked  by  traction  on  the  loop.  Without  this  the  opera- 
tion would  have  been  very  difficult. 

Old  Operation  for  Ligature  of  the  Common  Carotid. — 
This,  perhaps  the  most  formidable  operation  in  surgery,  was  success- 
fully made  use  of  by  Prof.  Syme  *  in  a  case  of  aneurism  the  result  of 
a  stab.  The  patient  was  aged  twenty.  The  aneurism,  about  the  size 
of  an  orange,  extended  between  the  trachea  and  sterno-mastoid,  and 
downwards  close  to,  or  rather  under,  the  clavicle.  Nearly  at  its  centre 
was  a  cicatrix.  It  was  increasing  in  size,  and,  other  treatment  having 
failed,  it  was  decided  to  perform  the  old  operation,  it  being  evidently 
impossible  to  apply  a  ligature  below  the  aneurism. 

"  I  pushed  a  knife  through  the  cicatrix,  and  followed  the  blade  with 
the  forefinger  of  my  left  hand  so  closely  as  to  prevent  any  effusion  of 
blood.  I  then  searched  through  the  clots  and  fluid  contents  of  the  sac 
for  the  wound  of  the  artery,  and  found  that  pressure  at  one  part  made 
the  pulsation  cease.    Keeping  my  finger  steadily  applied  to  this  point, 

*  Observ.  in  Clin.  Surg.,  p.  154. 


LIGATURE   OF   THE    COMMON    CAROTID.  443 

I  laid  the  cavity  freely  open  both  upwards  and  downwards,  turned  out 
the  clots,  and  sponged  awny  the  blood  so  as  to  get  a  view  of  the  bottom, 
which  presented  the  smooth,  shining  aspect  of  a  serous  membrane, 
without  the  slightest  indication  of  either  the  artery  or  vein  that  could 
be  seen  or  felt.  In  order  to  make  the  requisite  dissection,  I  next 
attempted  to  close  the  orifice  by  means  of  forceps,  but  found  that  it 
had  the  form  of  a  slit,  which  could  not  be  thus  commanded.  It  was 
also  so  near  the  clavicle  that  pressure  could  not  be  employed  below  it, 
and,  to  my  still  greater  concern,  lay  on  the  inner  or  tracheal  side  of  the 
vessel,  so  that  the  compression  required  for  its  closure,  instead  of  being 
backwards  on  the  vertebra,  was  outwards  upon  the  vein.  In  these 
circumstances  it  seemed  proper,  so  far  as  possible,  to  lessen  the  op- 
posing difficulties,  and  I  therefore  ran  a  bistoury  through  the  skin  and 
the  sternal  portion  of  the  sterno-mastoid.  I  then  seized  the  edge  of  the 
slit  in  the  artery,  as  it  lay  under  my  finger,  with  catch-forceps,  and 
desired  them  to  be  held  so  as  to  draw  the  vessel  towards  the  trachea ; 
I  then  carefully  scratched  with  the  point  of  a  knife  until  the  arterial 
coat  was  brought  into  view  at  its  external  edge,  a  little  above  the 
aperture,  where  a  ligature  was  passed  by  the  needle,  and  tied.  I  re- 
peated the  same  procedure  below  the  wound,  and,  when  it  was  com- 
pleted, had  the  satisfaction  of  finding  that  my  finger  could  be  with- 
drawn without  the  slightest  appearance  of  bleeding,  instead  of  the 
tremendous  gush  which  had  previously  attended  its  slightest  displace- 
ment. The  ligatures  separated  on  the  tenth  day,  and  the  patient 
recovered  completely." 

Prof.  Syme  considered  this  by  far  the  most  arduous  operation  he 
had  undertaken,  from  the  fact  that  "  the  slightest  displacement  of  one 
hand  must  have  instantaneouly  caused  a  fatal  haemorrhage  from  the 
carotid  artery,  and  a  wrong  direction  of  the  needle  by  the  other,  to  the 
smallest  possible  extent,  would  have  given  issue  to  an  irrepressible 
stream  from  the  jugular  vein." 

Mr.  Erichsen  *  gives  the  following  graphic  picture  of  the  difficulties 
of  the  operation :  "  The  haemorrhage  having  been  completely  arrested, 
either  by  compression  of  the  artery  above  the  tumor,  or  by  pressure 
of  the  fingers  at  the  opening  leading  into  the  tumor,t  you  lay  it  open 
freely  and  completely,  turn  out  the  coagula,  and  syringe  away  any 
dark  or  fluid  blood  which  may  be  there.     You  then  open  the  interior 

*  Lancet,  1868,  vol.  ii.  p.  505. 

t  Mr.  Erichsen  thus  puts  Prof.  Syme's  practical  point — "  to  make  a  small  opening 
into  the  tumor,  an  opening  just  sufficient  to  enable  you  to  insinuate  your  fingers,  and 
so  to  work  your  whole  hand  gradually  into  the  tumor  in  that  way,  so  that  the  entrance 
of  the  hand  may  plug  up  the  opening  into  the  sac;  to  feel  with  your  fingers  for  the 
opening  into  the  artery,  and  to  get  your  fingers  against  that,  so  as  to  restrain  the  flow 
of  blood  from  it,  before  the  rest  of  the  sac  is  laid  open." 


444  OPERATIONS    ON    THE    HEAD    AND    NECK. 

of  the  aneurism.  But  what  is  that  interior  ?  It  is  not  the  interior  of 
a  smooth  sac,  but  it  is  a  large  ragged  cavity  with  masses  of  coagulum 
or  solid  fibrin  sticking  to  it  in  different  directions,  with  the  remains, 
perhaps,  of  an  old  sacculated  aneurism  at  the  bottom,  with  a  quantity 
of  plastic  matter  infiltrating  the  tissues  around  it,  Avith  the  anatomical 
relations  of  the  parts  utterly  and  completely  disturbed  and  destroyed, 
with  great  thickening  and  solidification  of  the  parts  around  from  the 
pressure  to  which  they  have  been  subjected  in  consequence  of  the 
effusion  of  plastic  matter.  So  you  have  a  large  cavity  Avith  an  opening 
at  the  bottom  of  it,  the  opening  leading  to  the  artery  somewhere  or 
other,  but  the  position  of  the  artery  more  or  less  disturbed,  more  or 
less  masked  and  obscured  by  these  masses  of  coagulum,  by  this  plastic 
infiltration,  by  this  thickening  and  cohesion  of  the  tissues  to  one 
another  around  it.  The  i.ext  thing  is  to  pass  the  ligature  around  the 
artery.  Now,  the  artery  does  not  lie  exposed  in  this  sac;  quite  the 
contrary.  You  have  to  scrape,  or  to  dissect,  or  cut  through  the  poste- 
rior wall  of  the  sac,  which  always  overlies  the  artery.  That  consti- 
tutes the  great  difficulty  of  the  operation — to  open  up  this  posterior 
wall  in  a  proper  direction,  and  to  get  the  needle  round  the  part  with- 
out wounding  the  contiguous  vein,  or  transfixing  the  artery,  or  doing 
damage  to  the  neighboring  parts.  The  best  way  of  doing  that,  un- 
doubtedly, is  to  introduce  a  large  steel  probe  or  a  metallic  bougie  into 
the  opening  into  the  artery,  and  to  use  that  as  a  guide  to  the  situation 
of  the  vessel.  You  may  use  a  large  one  so  as  to  plug  up  the  opening.* 
....  You  then  clear  the  vessel  as  well  as  you  can — the  coats  are  gen- 
erally thickened  and  diseased  in  the  vicinity  of  the  aneurismal  tumor 
— and  you  pass  a  good  double  ligature  around  it." 

Difficulties  and  Possible  Mistakes  during  Ligature  of  the 
Oomnion  Carotid. 

1.  Altered  condition  of  the  soft  parts — e.g.,  matted  and  oedematous 
from  the  close  contiguity  of  an  aneurism,  from  previous  trial  of 
pressure ;  or  loaded  with  blood  or  inflammatory  products,  as  in  the 
case  of  a  wound. 

2.  Presence  of  an  aneurism  which  encroaches  upon  the  site  of 
incision. 

3.  Not  hitting  the  edge  of  the  sterno-mastoid.  This  muscle  may 
be  drawn  over  the  artery  if  the  chin  be  too  much  forced  to  the  opposite 
side.  The  chin  should  be  kept  about  midway  between  the  acromion 
and  the  episternal  notch  of  the  opposite  side  (Barwell). 

4.  Great  enlargement  of  the  superior  and  middle  thyroid  veins.f 

*  In  one  case,  as  stated  by  Mr.  Erichsen,  Mr.  Birkett  nsed  a  large  bougie  as  a  guide. 

t  Mr.  Barwell  {Intern.  Encycl.  Surg.,  vol.  iii.  p.  499)  says  tbat  tbe  superior  thyroid 
vein,  very  full  and  turgid,  sometimes  runs  before,  more  often  behind,  the  carotid.  "  I 
suppose  it  is  the  effect  of  the  ansesthetic  which  causes  this  to  swell  to  the  size  of  a  cedar 
pencil." 


LIGATURE  OF   THE   COMMOX  CAROTID.  445 

5.  An  enlarged  and  overlapping  thyroid  gland. 

6.  A  large  internal  jugular  overlapi^ing  the  artery. 

7.  Opening  the  sheath  towards  its  outer  side,  and  so  coming  down 
upon,  and  perhaps  injuring,  the  vein.* 

8.  Including  one  of  the  nerves  f  which  are  in  relation  with  the 
artery — e.g.,  the  descendens  noni,  the  vagus,  or  the  sympathetic. 

Causes  of  Failure  and  Death  after  Ligature  of  the  Com- 
mon Carotid. 

1.  Cerebral  complications — e.g.,  impaired  nutrition  and  softening. 
Mr.  Erichsen  X  thinks  that  "  cerebral  symptoms  "  (he  does  not  say 
whether  he  means  fatal  ones  or  no)  are  liable  to  occur  in  25  per  cent, 
of  ligatures  of  the  common  carotid.  The  symptoms  of  these  cerebral 
complications  ma}'-  come  on  almost  at  once  or  some  days  after  the 
operation.  Mr.  Erichsen  divides  them  into  two  sets — (1)  the  early 
ones,  resulting  from  the  too  small  supply  of  arterial  blood,  viz.,  syn- 
cope, twitchings,  giddiness,  impaired  sight,  and  hemiplegia ;  (2)  after 
the  above  have  been  present  for  a  few  days,  and  softening  has  taken 
place,  convulsions  and  death  ensue.§ 

It  would  be,  perhaps,  worth  while,  in  view  of  the  above  mortality, 
to  try  pressure  before  resorting  to  the  ligature,  in  order  that  the  oppo- 
site vessels  may  become  enlarged.  Pressure  could  only  be  kept  up, 
without  an  anaesthetic,  for  a  few  minutes  at  a  time,  and  care  would 
have  to  be  taken  not  to  apply  it  at  the  intended  site  of  ligature. 

*  On  the  dead  body,  especially,  there  is  a  risk  of  mistaking  the  flaccid  jugular  for 
fascia,  and  opening  it,  unless  the  sheath  has  been  opened  over  its  front  and  inner  part, 
as  should  be  always  the  practice. 

f  "The  descendens  noni  lies  usually  on  the  outer  part  of  the  sheath,  and  will  rarely 
be  endangered  if  that  structure  is  opened  as  above  described  ;  but  it  is  well  to  see  that 
it  is  out  of  the  line  taken  by  the  director;  if  its  absence  there  be  verified,  it  need  not 
be  hunted  up  elsewhere.  The  pneumogastric  lies  in  the  interval  between  the  artery 
and  vein  in  the  back  part  of,  but  not  loose  in,  the  sheath;  each  of  the  vessels,  as  well 
as  the  nerve,  has  a  compartment,  strongly  walled,  to  itself;  while  the  sympathetic, 
behind  the  sheath,  is  also  separated  by  a  thick  fascia  from  the  vessels.  If  tliese 
anatomical  positions  be  maintained,  both  nerves  are  safe.  Young  operators  are  some- 
times made  anxious  and  embarrassed  by  unnecessary  cautions,  yet  sometimes  the  parts 
do  not  quite  maintain  their  proper  positions.  Hence  it  is  well,  before  tightening  the 
ligature,  to  see  that  it  includes  the  artery  only." — Barwell  (loc.  supra  cit.). 

X  Surgery,  7th  edition,  vol.  ii.  p.  92.  In  his  calculations  Mr.  Erichsen  includes  four- 
teen cases  of  ligature  of  the  innominate,  though  not  one  of  the  thirteen  fatal  cases 
died  from  cerebral  trouble.  Mr.  Barwell  {loc.  supra  cit.)  argues,  from  the  fact  that  in 
no  case  of  ligature  of  the  innominate — an  operation  which  cuts  off  all  the  right  blood- 
supply — have  cerebral  symptoms  supervened,  that  there  must  be  some  other  cause  than 
brain  anaemia  for  these  complications. 

I  Mr.  Barwell  is  of  opinion  that  a  large  majority  of  the  cases  in  which  so-called 
cerebral  symptoms  supervened  from  the  seventh  to  the  tenth  day  were  cases  of  pytemia, 
and  in  some  cases  detachment  of  minute  portions  of  clot  may  have  been  the  cause. 


446  OPERATIONS   ON    THE    HEAD   AND    NECK. 

2.  Cellulitis  and  septic  complications. 

3.  Recurrent  pulsation.  In  most  cases  this  is  due  to  blood  finding 
its  way  round  from  the  opposite  side.  The  pressure,  however,  in  cases 
of  aneurism,  having  been  relieved,  coagulation,  as  a  rule,  takes  place, 
though  slowly. 

In  a  smaller  number  of  cases  the  recurrence  of  the  pulsation  has 
been  of  a  more  permanent  kind,  from  the  ligature  becoming  loosened 
or  dissolved,  especially  when  catgut  has  been  used. 

4.  Suppuration  of  the  sac.  Mr.  Erichsen  states  that  this  is  not  very 
uncommon.  "  In  the  majority  of  cases  the  patient  eventually  does 
well." 

5.  Htemorrhage.  This  has  never  been  a  common  complication, 
owing  to  the  absence  of  branches.  It  may  take  place  from  the  site  of 
ligature*  or  from  a  suppurating  sac.  It  should  be  still  more  rarely 
met  with  in  the  future,  owing  to  the  modern  treatment  of  wounds. 

6.  Low  forms  of  lung-inflammation.  Mr.  Erichsen  states  that  these 
are  not  uncommon.  He  attributes  them  to  diminished  freedom  of  the 
respiratory  movements  owing  to  the  disturbed  circulation  in  the 
brain  and  medulla. 

LIGATURE  OF  THE  EXTERNAL  CAROTID  (Fig.  89). 

This  operation  has  not  received  the  attention  which  it  deserves, 
having  been  too  often  set  aside  for  the  easier  operation  of  ligature  of 
the  common  trunk. 

Mr.  Cripps,t  discussing  the  ligature  of  the  external  carotid  in  the 
treatment  of  hajmorrhage  from  punctured  wounds  of  the  throat  and 
neck,  states  that  the  objections  raised  to  the  above  operation  are : 

1.  The  fear  of  secondary  haemorrhage  from  the  seat  of  ligature  due 
to  the  close  proximity  of  its  larger  branches. 

In  answer  to  this  he  refers  to  M.  Guyon's|  collection  of  twenty-seven 
cases  of  ligature  of  the  external  carotid,  to  which  he  adds  three.  In 
only  one  case  of  these  thirty  did  secondary  haemorrhage  occur.  Larger 
statistics  than  these  have  been  furnished  by  Dr.  Wyeth,  of  New  York. 
He  states  that,  of  sixty-seven  cases  in  which  the  external  carotid  alone 
was  tied,  three  died,  and  that  all  these  fatal  cases  were  from  gunshot 

*  This  danger  would  seem  to  increase  the  lower  down  the  ligature  is  placed.  Mr. 
Barwell  says  that  the  only  fatal  case  of  secondary  haemorrhage  he  has  had  in  this 
operation  followed  the  ligature  of  a  carotid  with  catgut  close  above  the  sterno-clavicular 
joint.     It  is  not  stated  whether  the  wound  was  aseptic  throughout  or  not. 

t  3fed.  Chir.  Trans.,  vol.  Ixi.  p.  234. 

X  Mem.  de  la  Soc.  de  Chir.,  vol.  vi.  According  to  Prof.  Agnew  {Prin.  and  Pract.  of 
Surg.,  vol.  i.  p.  636),  out  of  nineteen  cases  of  ligature  of  the  external  carotid  only  one 
proved  fatal  from  haemorrhage,  and  none  from  causes  which  could  properly  be  at- 
tributed to  the  operation. 


LIGATURE   OF   THE   EXTERNAL   CAROTID.  447 

injuries  in  military  practice.  One  of  these  fatal  cases  died  on  the 
table  from  the  effects  of  haemorrhage  before  the  ligature  could  be 
applied.  In  the  other  two  the  cause  of  death  is  not  given.  Of  the 
sixty-seven  cases,  haemorrhage  occurred  after  ligature  in  five,  none  of 
which  proved  fatal.  In  four  of  these  the  bleeding  was  noted  as 
occurring  at  the  seat  of  lesion  beyond  the  ligature.  In  one  the  point 
of  bleeding  is  not  given.  The  artery  was  tied  on  both  sides  in  two 
patients  and  both  recovered. 

Dr.  Bryant,  of  New  York,*  states  that  he  can  add  sixteen  cases  to 
the  above  sixty-seven,  and  that  in  only  one  of  these  did  the  subse- 
quent death  bear  the  least  relation  whatever  to  the  operation  itself. 

2.  The  futility  of  the  operation,  should  the  wounded  vessel  be  the 
internal  carotid. 

Mr.  Cripps  answers  this  objection  by  comparing  the  rareness  of  a 
woiind  of  the  internal  carotid  with  one  of  the  external  or  its  branches. 
He  points  out  that,  of  eighteen  cases  in  which  the  bleeding  vessel  was 
identified,  the  internal  one  was  wounded  twice  alone  and  once  in  con- 
junction with  the  external.f 

3.  The  external  carotid  is  less  easy  to  ligature  than  the  common. 
This  objection  will  not  be  considered  for  a  moment  by  a  surgeon 

who  knows  his  anatomy,  and  who  is  in  the  habit  of  operating. 
The  advantages  of  the  operation  are: 

1.  That  circulation  through  the  brain  is  not  in  the  least  interfered 
with.     Consequently,  one  large  element  of  danger  is  avoided  (p.  445). 

2.  The  incision  made  over  the  external  carotid  will  also  expose  the 
bifurcation  and  the  internal  carotid,  and  may  thus  lead  to  a  direct 
exposure  of  the  wounded  vessel. 

Indications. 

i.  Wounds  of  the  Trunk  and  of  its  Branches. — This  subject  has  been 
already  alluded  to  (p.  434).  While  it  cannot  be  denied  that  the  easier 
operation  of  ligature  of  the  common  trunk  has  answered  in  some  of 
these  cases,  it  has  also  certainly  failed  repeatedly.  Considering  the 
rarity  of  wounds  of  the  internal  carotid,  the  surgeon  will  do  more 
wisely,  in  the  case  of  a  wound  over  the  carotid  area,  to  expose  and  tie 

*  Ann.  of  Surg.,  August,  1887,  p.  122.  In  this  fatal  case  both  external  carotids  had 
been  tied  to  check  the  rate  of  progress  of  malignant  disease  of  the  lower  jaw,  floor  of 
mouth,  and  tongue,*which  had  been  operated  on  repeatedly  without  success. 

t  Mr.  Cripps's  list  is  interesting  to  the  surgeon.  In  the  first  10  it  is  to  be  presumed 
that  ligature  of  the  external  carotid  would  have  been  the  wiser  course.  In  2  the 
bleeding  came  from  the  external  carotid;  in  1,  the  lingual;  in  1,  the  facial;  in  1, 
a  tonsillar  branch;  in  1,  a  branch  in  the  parotid  gland  ;  in  2,  the  internal  maxillary  ; 
in  1,  the  inferior  dental ;  in  1,  the  middle  meningeal ;  in  1,  the  vertebral ;  in  2,  the 
internal  carotid  ;  in  1  the  external  also  was  wounded  ;  in  1  the  source  was  close  to 
the  bifurcation;  in  2  the  common  carotid,  at  the  point  of  bifurcation,  was  wounded  ;, 
in  1,  the  ascending  pharyngeal. 


448  OPERATIONS  ON  THE  HEAD  AND  NECK. 

the  external  carotid  low  down  in  any  cases  of  doiilDt,  that  the  trunk 
and  the  internal  carotid  may  be  exposed  as  well,  if  needful. 

Mr.  Rivington  has  recorded  *  an  interesting  case  of  a  wound  of  the 
external  carotid  by  a  stab  in  the  parotid  region  giving  rise  to  recurrent 
attacks  of  haemorrhage,  and  treated  successfully  by  temporary  f  liga- 
ture of  the  common  carotid  and  ligature  of  the  external  carotid  at  the 
seat  of  injury. 

A  man,  aged  thirty-one,  was  admitted  into  the  London  Hospital 
with  three  wounds,  one  severing  the  lobule  of  the  left  ear  and  passing 
into  the  parotid  gland  below  the  zygoma,  a  second  behind  the  ear,  and 
a  third  over  the  mastoid  process.  Hemorrhage,  occurring  about  a 
week  later,  was  stopped  by  pressure.  Erysipelas  followed,  and  an  ab- 
scess was  opened  in  front  of  the  ear.  About  three  weeks  after  the 
accident,  haemorrhage  again  occurred,  being  brought  on  by  a  fit  of 
coughing,  blood  running  out  from  all  the  incisions.  Though  it  was 
again  arrested  by  pressure,  Mr.  Rivington  judged,  from  the  size  of  the 
stream  and  the  force  of  the  jet,  that  the  injured  vessel  must  have  been 
the  external  carotid  on  the  parotid  gland. 

On  account  of  the  difficulty  of  securing  the  artery  at  the  seat  of 
injury,  and  the  amount  of  blood  which  would  be  lost  before  this  could 
be  accomplished,  and  not  being  able  to  rely  upon  pressure  on  the 
common  carotid  during  the  operation,  Mr.  Rivington  cut  down  first 
on  the  common  trunk  at  its  bifurcation  |  and  placed  a  temporary  liga- 
ture of  catgut  round  it,  tying  this  lightly  so  as  to  stop  the  current  of 
blood,  but  not  to  divide  the  inner  and  middle  coats. 

The  openings  in  the  parotid  region  being  explored  and  clots  turned 
out,  a  little  below  the  angle  of  the  jaw  was  found  a  hole  from  which 
some  blood  issued  in  a  feeble  stream.  The  external  carotid  was  liga- 
tured above  and  below  this  spot.  The  ligature  in  the  main  trunk  was 
then  untied,  and  left  in  situ  for  use  if  needed.  All  bleeding  had  ceased 
and  there  was  no  recurrence.  The  patient  made  a  good  recovery, 
some  weakness  of  the  ftice  muscles  having  almost  disappeared  when 
he  left  the  hospital  two  months  after  the  accident. 

Mr.  Rivington  draws  attention  to  the  advantage  of  the  temporary 
ligature  on  the  main  trunk,  rendered  very  evident  by  the  fact  that 
immediately  before  the  operation,  when  the  sponge  was  removed  arte- 
rial blood  spirted  out  in  a  lively  jet,  whilst  after  the  ligature  a  languid 
stream  only  issued,  from  the  distal  sidfe  of  the  hole  in  the  external 
>carotid.     He  further  points  out  that  the  emj^loyment  of  temporary 

*  Clin.  Sbc.  Trans.,  vol.  xvii.  p.  79. 

f  Some  cases  in  which  Mr.  Treves  has  more  recently  made  use  of  this  step  are  given 
at  p.  441. 

X  It  remained  uncertain  whether  this  temporary  ligature  was  placed  on  the  external 
•or  the  common  carotid. 


LIGATURE    OF   THE    EXTERNAL    CAROTID. 


449 


ligatures,  either  lightly  tied  or  left  in  situ  for  use  in  case  of  need,  is 
capable  of  wider  application  in  the  treatment  both  of  hannorrhage  and 
of  aneurisms. 

ii.  Aneurism  by  Anastomosis  of  Scalp  and  Side  of  Head  and  Neck 
(Fig.  88). — Here  the  ligature  of  the  external  carotid  should  only  be 
made  use  of  as  an  adjunct  to  local  treatment,  or  Avhere  this  has  failed. 

If  the  growth  is  not  too  large,  it  should  be  excised  with  antiseptic 
precautions,  tying  each  vessel  as  it  is  cut.  The  operation  may  be 
rendered  partly,  if  not  entirel}',  evascular,  by  the  use  of  stout  india- 
rubl)er  bands  passed  round  the  back  of  the  head  and  the  lower  jaw, 
with  pledgets  of  lint  over  the  main  vessels — eg.,  temporal  or  external 
carotid,  posterior  auricular,  and  occipital.  Another  method  is  one 
made  use  of  by  Mr.  Hutchinson*  in  the  removal  of  an  enormous 
fibro-cellular  tumor  of  the  scalp — viz.,  a  Petit's  tourniquet  passed 
around  the  back  and  sides  of  the  liead  and  lower  jaw  (p.  151). 

If  the  above  are  not  applicable,  the  external  carotid  may  be  tied 
preliminary   to   removing 

the  tumor.     When  this  is  ^^^-  ^^• 

being  eflfected,  any  skin 
that  is  not  too  much  in- 
volved should  be  pre- 
served. If  this  is  impos- 
sible, the  growth  must  be 
taken  away  with  the  skin 
over  it,  the  vessels  being 
secured  as  cut.  Every 
pains  must  be  taken  to 
keep  the  Avound  aseptic, 
and  thus  promote  rapid 
granulation-healing,  com- 
pleted by  skin-grafting. 

If  the  tumor  cannot  be 
excised,  it  should  be 
treated  by  underrunning 
the  main  vessels  of  sup- 
ply with  pins,  in  order  to 
bring  about  their  closure 
and  ultimately  the  oblit- 
eration of  the  growth. 

The  case  from  which  Fig.  88  is  taken  was  that  of  a  woman,  aged 
twenty-two,  who  was  thus  treated  by  Sir  W.  Fergusson.f     The  com- 


(Fergusson.) 


*  Land.  Hosp.  Beps.,  vol.  ii.     See  also  the  cases  referred  to  above,  p.  15L 

f  Pi-aciical  Surgery,  4th  edition,  p.  162,  Fig.  73. 

29 


460  OPERATIONS    ON    THE    HEAD    AND    NECK. 

mon  carotid  had  been  previously  tied  by  Mr.  Storks,  but  the  vessels 
slowly  increased  in  size.  Long  needles  were  passed  under  and  through 
the  vessels  at  the  most  prominent  points,  being  sufficiently  strong  to 
bear  the  pressure  made  by  twisting  strong  threads  about  them  over 
the  included  vessels  and  scalp.  At  some  points  sloughing  occurred, 
elsewhere  ulceration  loosened  the  needles,  and  throughout  the  parts 
interfered  with  there  was  inflammation  and  induration.  In  about 
three  weeks,  as  anticipated,  haemorrhage  took  place.  Digital  pressure 
was  made  use  of  till  fresh  needles  were  introduced  and  the  old  ones 
withdrawn,  when  threads  were  again  applied  and  the  bleeding  arrested. 
Further  inflammation  and  obliteration  of  the  vessels  ensued,  repeated 
hcemorrhages  were  arrested  in  a  similar  manner,  the  formidable  affec- 
tion being  ultimately  completely  obliterated. 

In  a  similar  case  it  would  probably  be  wiser  to  tie  the  external  car- 
otid before  inserting  the  pins. 

The  following  case,  published  by  Mr.  Wood,*  is  an  excellent  in- 
stance of  the  same  treatment  aided  by  the  antiseptic  advantages  of  the 
present  day : 

A  man,  aged  thirty-seven,  had  a  pulsating  tumor  in  the  right  parie- 
tal region  of  the  size  of  a  hen's  egg,  with  a  bruit,  together  with  a  pul- 
sating swelling  running  forwards  to  the  left  orbit,  the  eyeball  being 
pushed  forwards,  while  a  loose,  pulpy,  ntevoid  condition  extended 
into  the  occipital  region.  With  antiseptic  precautions,  stout  steel  pins 
were  run  under  the  right  supra-orbital,  temporal,  and  occipital  arte- 
ries. The  left  occiiDital  and  temporal  had  to  be  occluded  before  the 
pulsation  stopped,  and  four  pins  were  also  passed  under  the  swelling 
itself  and  its  neighborhood.  The  pins  were  passed  quite  down  to  the 
bone,  and  were  made  to  emerge  clear  beyond  the  vessels.  These  were 
compressed  with  silk  over  thick  india-rubber  pads,  which  served  to 
tighten  up  the  pressure  as  the  pins  cut  through.  About  an  hour  after 
the  operation  intense  neuralgic  pain  in  the  occipital  region  was  expe- 
rienced from  inclusion  of  the  nerve.  The  antiseptic  precautions  were 
stopped  in  ten  weeks,  and  the  patient  was  quite  cured  without  any 
bleeding,  suppuration,  or  sloughing,  save,  to  a  very  limited  extent,  at 
one  spot. 

As  these  cases  are  most  obstinate,  my  readers  will  excuse  me  if  I 
draw  their  attention  to  another  case  proving  that  ligature  of  the  ex- 
ternal carotid  (even  if  performed  on  both  sides)  is  not  likely  to  be 
successful  without  local  treatment  as  well — viz.,  either  underrunning 
the  vessels  with  pins,  or  excision.  It  is  recorded  by  Dr.  Bryant,  of 
New  York.f     The  patient,  aged  twenty-four,  had  a  well-defined  pul- 

*  Lancet,  1881,  vol.  ii.  p.  255. 

f  Annals  of  Surgery,  August,  1887,  p.  116, 


LIGATURE    OF   THE    EXTERNAL    CAROTID.  451 

sating  tumor  at  the  site  of  a  healed  scalp-wound  in  front  of  the  left  ear. 
The  trunk  and  branches  of  the  temporal  and  the  occipital  were  con- 
cerned in  the  growth.  As  this  was  rapidly  increasing,  the  left  external 
carotid  was  tied  with  catgut  about  half  an  inch  above  its  origin. 
Tj'ing  the  lingual  artery  also  provided  a  branchless  portion  of  the 
external  carotid  about  an  inch  in  extent.  The  ascending  pharyngeal 
was  sought  for,  but  not  found.  All  pulsation  was  at  once  checked, 
and  the  growth  was  also  reduced  to  about  one-third  of  its  previous 
size.  The  operation  was  antiseptic  throughout,  and  when  the  dress- 
ings were  changed  for  the  first  time  in  ten  days,  a  slight  return  of 
pulsation  was  noticed  in  the  tumor.  A  month  after  the  operation, 
pulsation,  thrill,  and  bruit  were  nearly  as  strong  as  before,  and  it  was 
decided  to  attack  the  tumor  itself  in  preference  to  tying  the  occipital 
and  temporal  branches  or  the  right  external  carotid.  The  arterial 
circulation  was  admirably  controlled  by  surrounding  the  head  with 
two  strong  rubber  bands,  beneath  which  compresses  were  placed  at 
the  points  where  arteries  passed  to  supply  the  seal]?.  Dr.  Bryant  has 
found  eight  other  cases  of  ligature  of  the  external  carotid  for  the  cure 
of  aneurismal  tumors  of  the  head,  face,  and  parotid  gland,  in  two  of 
which  both  the  vessels  were  tied  simultaneously.  This  latter  pro- 
cedure is  not  reported  to  have  been  successful  in  either  case.  Of  a  total 
of  nine  cases,  only  one,  a  traumatic  aneurism  of  the  parotid,  was  cured 
by  ligature  alone. 

Thus  it  would  appear  that  local  remedies — viz.,  excision  and  under- 
running,  aided  by  ligature  of  the  chief  feeding  arteries — are  most 
likely  to  be  successful  in  this  disease,  which  so  often  baffles  treatment. 
Ligature  of  the  external  carotid,  on  one  or  both  sides,  will  fail,  owing 
to  the  free  collateral  circulation,  if  tried  by  itself  even  in  recent  trau- 
matic cases  without  much  general  dilatation  of  the  vessels.  If  used 
at  all,  it  should  be  so  as  an  adjunct  and  a  preliminary  step  to  dimin- 
ish the  vascularity  of  the  tumor  before  this  is  dealt  with  locally  by 
the  methods  above  indicated. 

iii.  Aneurism  of  the  External  Carotid. — The  treatment  of  this  rare 
condition  has  been  already  discussed  at  p.  432. 

iv.  As  a  Preparatory  Step  to  extirpating  Malignant  Tumors  of  the 
Upper  Jaw,  Pharynx,  etc.,  or  as  a  Palliative  Step  where  the  above 
Extirpation  cannot  be  attempted.— This  question  has  already  been 
discussed  at  p.  437.  The  following  cases,  just  published,*  are  of 
interest  as  bearing  on  this  matter.  In  each  of  these  cases  repeated 
operations  had  been  performed  for  removal  of  malignant  disease  in- 
volving the  lower  jaw,  floor  of  the  mouth,  and  more  or  less  of  the 
tongue.     Rapid  recurrence  had  taken  place  in  each  case,  until,  the  use 


*  Dr.  Bryant,  Ann.  of  Sury.,  August,  1887,  p.  121. 


452  operatiojS'S  on  the  head  and  neck. 

of  the  knife  no  longer  seeming  feasible,  the  only  course  seemed  to  be 
starvation  of  the  growth.  Accordingly  this  was  attempted  by  simul- 
taneous ligature  of  both  external  carotids,  by  incisions  in  the  usual 
place,  the  enlarged  lymphatic  glands  found  being  removed.  When 
the  carotids  were  reached,  most  unusual  anomalies  were  found.  The 
right  common  carotid  bifurcated  beneath  the  posterior  belly  of  the 
digastric,  which  was  divided  to  admit  of  passing  the  ligature.  On  the 
left  the  bifurcation  was  behind  the  hypo-glossal  nerve,  which  was 
drawn  down,  and  the  ligature  then  passed  just  below  the  digastric. 
The  lingual  and  facial  branches  were  not  seen  on  the  right  side,  but 
this  caused  no  apprehension,  as  the  facial  was  said  to  have  been  tied 
some  months  before,  during  removal  of  the  diseased  submaxillary 
gland  on  that  side.  On  the  left  side  the  branches  of  the  external  car- 
otid were  normal.  The  operations  were  antiseptic  throughout.  The 
malignant  growth  diminished  in  size  rapidly,  the  discharge  became 
scanty,  thin,  and  watery,  and  the  ability  to  speak  and  swallow  im- 
proved quickly.  On  the  fifth  day  a  portion  of  the  growth  on  the  right 
side  sloughed  out,  leaving  an  aperture  bounded  by  sloughy  tissue,  at 
the  bottom  of  which  could  be  seen  necrosed  bone  in  the  lower  jaw. 
Nine  days  after  the  operation  profuse  haemorrhage  took  place,  with  a 
fatal  result.  This  haemorrhage  was  caused  by  sloughing  of  some  of 
the  diseased  starved  tissue,  into  which  the  trunk  common  to  the  facial 
and  lingual  passed. 

In  the  second  case  of  Dr.  Bryant  no  haemorrhage  or  sloughing  fol- 
lowed on  the  ligature  of  the  external  carotids.  For  two  months  the 
state  of  the  patient  was  much  improved,  the  growth  showed  but  little 
tendency  to  increase,  and  the  pain  and  dysphagia  did  not  return- 
Then  profound  cancerous  cachexia  set  in,  with  emaciation  and  loss 
of  strength,  beyond  which  there  is  no  note  of  the  patient. 

v.  Hsemorrhage  from  Middle  Meningeal  Artery  after  trephining. — 
This  matter  has  been  fully  considered  at  p.  178,  where  it  is  shown 
that  severe  haemorrhage  is  not  uncommon  after  a  wounded  middle 
meningeal  has  been  exposed  by  trephining,  but  that  the  bleeding  will 
usually  yield  to  measures  short  of  ligature  of  the  external  carotid. 

Guide. — The  anterior  border  of  the  sterno-mastoid  above  the  hyoid 
bone. 

Relations. — The  external  carotid  extends  from  the  upper  border 
of  the  thyroid  cartilage  to  a  point  midway  between  the  external  audi- 
tory meatus  and  the  condyle  of  the  jaw;  beyond  this  point  it  is  con- 
tinued on  as  the  temporal,  having  just  before  given  off  the  internal 
maxillary.  In  the  first  part  of  its  course  the  external  is  somewhat 
nearer  the  middle  line  than  the  internal  carotid,  and  is  more  superfi- 
cial than  this  throughout. 


LIGATURE    OF    THE    EXTERNAL,    CAROTID. 


453 


In  Front. 
Skin  ;  fascise ;  platysma  ;  nerves  from  transverse  cervical 

and  facial ;  superficial  veins. 
Lingual  and  facial  veins. 
Digastric  and  stylo-hyoid. 
Parotid,   facial    nerve ;     temporo-maxillary   aiid    other 

veins. 


Inside. 
Pharynx. 
Hyoid  bone. 
Ramus  of  jaw. 
Parotid. 


Outside. 

Parotid, 

Temporo-maxillary  vein,  when 
this  descends  to  join  the  in- 
ternal jugular. 


External 
carotid. 


Behind. 
Parotid  gland. 
Superior  laryngeal. 
Glosso-pharyngeal. 
Stylo-glossus  and  stylo-pharyngeus. 

The  veins  in  relation  with  the  external  carotid  vary  a  good  deal. 
But,  in  addition  to  the  lingual  and  facial  crossing  it,  a  number  of 
veins  joining  the  external  and  anterior  to  the  internal  jugular  may 
form  a  kind  of  plexus  round  the  artery,  and  the  temporo-maxillaiy 
may  descend  outside  the  artery  to  join  the  internal  instead  of  the 
external  jugular. 


Branches  :  * 
Anterior. 
Superior 

thyroid. 
Lingual. 


Posterior. 
Auricular. 
Occipital. 


Ascending. 
Ascending 
pharyngeal. 


Terminal. 
Temporal. 
Internal 

maxillary 


Facial. 

Operation. — This  is  performed  at  two  spots  : 

a.  Below  the  digastric  (Fig.  89). 

h.  Above  this  muscle,  behind  the  ramus  of  the  jaw. 

a.  Below  the  Digastric. — This  is  the  operation  more  frequently 
performed  in  order  to  cut  off  the  blood-supply  through  all  the 
branches  of  the  artery.     Though  these  are  so  numerous,  and  vary 


*  While  this  is  a  common  arrangement,  it  is  by  no  means  the  only  one.  Very  fre- 
quently one  trnnk  gives  off  two  or  three  arteries.  Sometimes  all  the  branches,  save 
the  two  terminal,  arise  very  close  together,  the  external  carotid  constituting  them  an 
arterial  axis.  It  is  the  presence  of  these  branches  which  enables  tiie  surgeon  to 
decide  whether  he  is  dealing  with  the  external  or  internal  carotid. 


454 


OPERATIONS   ON    THE    HEAD    AND   NECK. 


somewhat,  there  is  usually  a  sjiot,  varying  from  ?  to  f  inch,  between 
the  superior  thyroid  and  the  hngual  on  which  a  ligature  may  be 
safely  placed,  especially  if  the  superior  thyroid  and  linguals  are  liga- 
tured as  well  (p.  451). 

The  position  of  the  patient's  head  and  the  surgeon  being  the  same 
as  in  the  operation  on  the  common  trunk,  an  incision  2i  to  3  inches 

Fig.  89. 


Ligature  of  the  temporal,  facial,  external  carotid,  and  occipital  artery  is  shown  here.  In  the 
ligature  of  the  external  carotid,  the  angle  of  the  jaw,  digastric,  and  opened  deep  cervical  fascia 
are  seen  above.  Overlying  the  artery  is  an  enlarged  lymphatic  gland  ;  outside  it  is  the  inner 
edge  of  the  sterno-ma.stoid  ;  the  facial  vein  crosses  it,  and  descending  to  join  this  on  the  inner 
side  is  a  large  communicating  branch  from  the  internal  maxillary  vein.  The  occipital  artery  is 
shown  ligatured  behind  the  mastoid  process.  The  edges  of  the  cut  posterior  half  of  the  sterno- 
mastoid  are  shown  in  the  upper  and  lower  parts  of  the  wound.  Above  the  artery,  under  the 
upper  part  of  the  thread,  is  a  part  of  the  splenius  capitis,  cut.  The  vessel  itself  rests  on  some 
fascia  continuous  with  that  over  the  complexus. 

long  is  made,  in  the  line  of  the  artery,  from  the  angle  of  the  jaw  to  the 
upper  border  of  the  thyroid  cartilage,  about  i  inch  in  front  of  the 
anterior  border  of  the  sterno-mastoid.     This  incision  should  divide 


LIGATURE   OF   THE    INTERNAL    CAROTID.  455 

skin,  fascife,  and  platysma ;  any  superficial  veins  being  secured,  the 
cellular  tissue  in  front  of  the  muscle  is  opened  up,  and  the  posterior 
belly  of  the  digastric  or  the  hypo  glossal  sought  for  as  guides  to  the 
vessel.  In  doing  this  the  sterno-mastoid  should  be  drawn  outwards, 
any  large  veins — e.g.,  facial  or  lingual — pulled  aside  with  a  strabismus 
hook  or  secured  with  double  chromic -gut  ligatures  before  division. 
The  muscle  or  the  nerve  being  defined,  the  pulsation  of  the  artery  is 
felt  for  below  them,  and  the  vessel  carefully  cleaned  just  above  the 
thyroid  cartilage.  The  use  of  the  steel  director  or  knife  should  be 
most  cautious  on  the  outer  side  of  the  artery,  where  lie,  below,  the 
internal  jugular  and  internal  carotid.  At  the  same  time  the  presence 
of  the  descendens  noni  on  the  artery  is  to  be  remembered,  and  that  of 
the  superior  laryngeal  nerve  running  obliquely  downwards  and 
inwards  behind  the  vessel.  The  needle  should  be  passed  from  with- 
out inwards.  The  superior  thyroid  and  lingual  should  be  ligatured 
at  the  same  time,  and  the  ascending  pharyngeal  if  it  can  be  found. 

h.  Above  the  Digastric,  behind  the  Ramus  of  the  Jaw. — 
This  operation  has  the  disadvantage  of  probably  entailing  the  division 
of  important  branches  of  the  facial  nerve. 

The  head  and  shoulders  being  duly  raised  and  supported,  the  sur- 
geon makes  an  incision  downwards  from  the  tragus  of  the  ear,  just 
behind  the  ramus  of  the  jaw,  dividing  the  skin  and  fasciae.  The 
sterno-mastoid  must  be  now  drawn  outwards  and  the  digastric  and 
stylo-hyoid  downwards,  and  it  will  probably  be  needful  to  divide 
these  latter  muscles  partially  in  order  to  secure  the  artery  before  it 
enters  the  parotid  gland,  this  structure  being  drawn  upwards  and 
forwards. 

The  needle  may  be  passed  from  either  side  as  is  most  convenient  to 
the  surgeon. 

Several  veins  communicating  between  the  facial  and  the  external 
jugular  will  probably  cross  the  line  of  incision,  and  must  be  dealt 
with. 

LIGATURE  OF  THE  INTERNAL  CAROTID. 

Indications. — These  are  extremely  few. 

1.  Wounds,  usually  Stabs. — The  following  striking  case  is  quoted 
by  Dr.  Lidell,*  and  reflects  the  greatest  credit  on  the  medical  men 
concerned : 

On  July  31,  1869,  a  man  was  Avounded  in  the  neck,  at  the  angle  of 
the  lower  jaw,  by  the  large  blade  of  a  pocket-knife,  which  penetrated 
several  inches,  opening  the  internal  carotid.  Alarmed  by  the  tremen- 
dous outjets  of  arterial  blood,  Dr.  Denning,  in  whose  drug-store  the 

*  Intern.  Encycl.  of  Surg.,  vol.  iii.  p.  HI ;  Amer.  Journ.  Med.  &i.,  January,  1879,  pp. 
142,  143. 


456  OPERATIONS   ON   THE   HEAD    AND   NECK. 

stabbing  occurred,  at  once  compressed  the  carotids.  Happening  to  be 
close  at  hand,  Dr.  A.  T.  Lee  promptly  cut  down  upon  the  artery  by 
the  usual  incision,  exposed  it  by  careful  dissection,  found  the  bleed- 
ing-point, and  applied  a  ligature  on  the  cardiac  side  of  it.  Haemor- 
rhage now  occurring  from  the  upper  end  was  arrested  by  a  ligature 
on  the  distal  side  of  the  wound.  The  patient  was  now^  pulseless,  and 
death  was  considered  imminent,  but,  under  energetic  stimulation 
with  whisky  and  ammonia,  the  circulation  soon  became  good,  and  the 
patient  made  a  good  recovery,  being  in  active  work  nine  years  later. 

2.  Aneurism.* — If  this*  is  non-traumatic  f  in  origin  andsacculated, 
the  decision  as  to  treatment,  if  pressure  has  failed,  must  lie  between 
the  Hunterian  operation  of  ligaturing  the  common  carotid,  or,  if  the 
artery  is  sound,  and  if  there  be  room  above  as  well  as  below  the  aneu- 
rism, of  placing  ligatures  above  and  below  the  sac,  and  opening  this 
to  turn  out  the  clots.  But  one  or  both  of  these  conditions  may  very 
likely  be  aljsent. 

If  the  aneurism  be  traumatic  in  origin,  resulting  from  a  stab  or 
gunshot  injury  in  the  neck,  or  if,  in  spite  of  other  treatment,  it  is 
steadily  increasing,  the  only  operation  likely  to  avail  is  the  old  one. 

The  following  cases  are  excellent  instances  of  the  difficulties  which 
may  be  met  with  in  these  cases,  and  how  they  should  be  met : 

Dr.  Prewitt,  of  St.  Louis,|.  has  recorded  the  following  most  interesting 
case  of  traumatic  aneurism  following  a  gunshot  injury  :  A  negress, 
aged  seventeen,  was  shot  with  a  revolver  bullet,  which  entered  the 
cheek  over  the  malar  bone  and  passed  backwards.  Profuse  hsemor- 
rhage  took  place  at  once  from  the  wound  of  entrance,  there  being  none 
of  exit.  This  was  controlled  by  pressure.  A  swelling  quickly  ap- 
peared between  the  ramus  of  the  jaw  and  the  mastoid  process,  which 
three  months  later  was  found  to  project  into  the  pharyngeal  cavity, 
crowding  the  tonsil  over  the  middle  line  and  resting  against  the  uvula. § 

*  Aneurism  of  tlie  internal  carotid  liere  refers  to  the  cervical  part  of  the  artery. 
The  treatment  of  orbital  aneurism,  which  often  depends  on  arterio-venous  communi- 
cation (traumatic  or  idiopathic)  between  the  internal  carotid  and  the  cavernous  sinus, 
has  already  been  considered  at  p.  432. 

f  The  rareness  of  disease,  and  thus  of  idiopathic  aneurism,  here  is  well  known. 

%  Trans.  Amer.  Surg.  Assoc,  vol.  iv.  p.  233. 

§  With  reference  to  this  tendency  of  internal  carotid  aneurisms  to  project  inwards, 
Dr.  Prewitt  thus  quotes  from  Prof.  Agnew  [Surgery,  vol.  i.  p.  591)  :  "The  deep  situ- 
ation of  the  artery,  covered  as  it  is  externally  by  the  stylo-hyoid,  stylo-pliaryngeiis, 
and  stylo-glossus  muscles,  and  by  dense  aponeurotic  structures,  which  extend  down  to 
the  styloid  process,  prevents  any  very  marked  prominence  of  such  a  tumor  on  the  sur- 
face of  the  neck,  and,  as  the  artery  is  separated  from  the  pharynx  only  by  the  mucous 
membrane  and  the  constrictor  muscle,  its  extension  inwards  becomes  an  anatomical 
necessity.  Indeed,  in  this  peculiarity  lies  the  chief  difference  between  aneurism  of  the 
internal  carotid  and  aneurism  situated  at  the  division  of  the  common  trunk  " 


LIGATURE    OF    THE    INTERNAL    CAROTID.  467 

Externally  the  swelling  "reached  from  the  temporal  hone  to  the  hyoid. 
Expansile  pulsation,  well-marked  bruit,  and  thrill  were  present.  Sense 
of  taste  was  lost  in  the  right  side  of  the  tongue,  which  was  atrophied, 
and,  when  protruded,  inclined  to  the  right.  Pressure  on  the  common 
carotid  arrested  pulsation  in  the  tumor,  and  caused  some  decrease  in 
size.  There  was  no  perceptible  difference  in  the  right  and  left  tem- 
poral pulses;  the  pupils  were  equal.  There  Avas  persistent  headache, 
and  sometimes  roaring  in  the  right  ear.  Difficulty  in  swallowing  had 
existed  from  the  first.     The  general  condition  was  unsatisfactory. 

It  was  decided  to  tie  the  common  carotid  at  once,  but  though  the 
pulsation  and  thrill  in  tlie  sac  seemed  arrested  at  first,  they  returned 
in  a  few  minutes.  It  was  then  decided,  as  a  forlorn  hope  (because  the 
diagnosis  had  placed  the  opening  of  the  sac  close  to  the  carotid 
foramen),  to  extend  the  incision  upwards  in:  front  of  the  tragus  to  de- 
termine the  feasibility  of  laying  open  the  sac  and  tying  the  vessel  upon 
the  distal  side  of  it. 

A  cautious  dissection*  at  the  back  and  upper  part  of  the  sac  showed 
that  this  filled  all  the  space  between  the  mastoid  process  behind  and 
the  condyle  and  ramus  of  the  jaw  in  front,  the  sac  seeming  also  to 
blend  with  the  skull  or  to  be  closely  adherent  to  it.  A  little  reflection 
made  it  apparent  that  any  attempt  to  deal  with  the  sac  after  the 
method  of  Mr.  Syme  would  in  in  all  probability  prove  disastrous,  as 
it  would  almost  certainly  be  found  that  th^re  was  no  portion  of  the 
artery  between  the  carotid  foramen  and  the  sac  to  be  tied.  The  wound 
was  washed  out  with  bichloride  solution,  drained,  and  closed.  On  the 
evening  of  the  eighth  day,  there  having  been  pyrexia  and  free  suppu- 
ration of  the  wound  in  the  interval,  hsemorrhage  took  place  from  the 
sac.  The  wound  was  enlarged,  and  search  made  with  the  finger  for 
the  orifice  of  the  artery  or  the  carotid  foramen.  The  search  being 
fruitless,  and  it  seeming  certain  that  laying  open  of  the  sac  or  re- 
moval of  the  finger  would  be  followed  by  speedily  fatal  haemorrhage, 
the  sac  was  strapped  with  strips  of  lint  rolled  in  iodoform.  Hannor- 
rhage  did  not  recur,  but  the  patient  died  exhausted  twenty-five  days 
after  the  first  operation. 

The  autopsy  was  conducted  under  great  difficulty,  but  it  was  thought 
that  it  was  made  out  that  the  opening  in  the  artery  was  close  to  the 
carotid  foramen.  Death  seemed  largely  due  to  septic  causes,  e.g.^ 
thrombosis  of  the  inferior  petrosal  and  of  the  lateral  sinuses. 

Dr.  Prewitt  points  out  that  such  an  aneurism  might  be  mistaken  for 

*  It  was  suggested  by  Prof.  Agnew,  at  the  discussion  on  this  paper,  that  the  jaw 
should  hnve  been  divided  and  the  pieces  pulled  aside  to  fiicilitate  further  dissection,  but 
Dr.  Prewitt  found  that  the  j;iw  and  sac  were  closely  adherent,  and,  even  if  separation 
could  have  been  effected,  there  would  have  been  no  artery  above  that  could  have  been 
tied. 


458  OPERATIONS    ON   THE   HEAD    AND   NECK. 

one  of  the  occipital,  vertebral,  and  perhaps  of  the  internal  maxillary 
or  one  of  its  branches.  The  chief  diagnostic  points  are  the  projection 
into  the  pharynx,  the  evidence  of  pressure  on  the  vagus  and  glosso- 
pharyngeal (p.  456),  and  the  exclusion  of  the  vertebral,  by  the  effects 
of  pressure  below  the  sixth  cervical  vertebra  (p.  461).  He  also  shows 
by  several  cases  that  aneurism  of  the  internal  carotid  has  repeatedly, 
owing  to  the  interference  with  speech  and  swallowing,  the  pain  in  the 
neck,  and  the  difficulty  in  opening  the  mouth,  been  taken  for  tonsillar 
abscess,  and  with  fatal  results.  One  of  these  cases  may  be  quoted 
here : 

A  man,  aged  twenty-eight,  was  shot,  on  September  30, 1879,  through 
the  right  infra-orbital  region.  No  haemorrhage.  At  the  end  of  a  week 
the  swelling  in  the  face  had  entirely  subsided,  but  tumefaction  of  the 
right  side  of  the  neck  remained.  On  the  eighth  day  the  patient  was 
out.  On  the  fifteenth  he  called  at  Dr.  Lee's  office,  and  complained  of 
inability  to  speak  or  swallow,  and  also  of  severe  j^ain  in  the  right  side 
of  the  neck,  which  he  said  he  could  not  bend.  His  appearance  was 
that  of  a  man  suffering  from  severe  tonsillitis.  With  considerable 
difficulty  Dr.  Lee  succeeded  in  opening  the  patient's  mouth  enough  to 
permit  of  limited  inspection.  The  tonsils  and  soft  palate  were  so 
swollen  as  to  preclude  inspection  of  the  pharynx.  On  the  hard  palate 
there  was  a  small  firm  tumor  about  the  size  of  a  hickory-nut.  Think- 
ing this  might  be  the  ball  surrounded  by  inflammatory  products,  an 
exploratory  incision  was  made.  On  the  removal  of  some  clots  of  blood, 
there  was  a  gush  of  arterial  blood.  In  consequence  of  the  struggles 
of  the  patient.  Dr.  Lee  was  unable  to  control  the  haemorrhage,  and 
death  ensued  in  a  few  minutes. 

In  the  discussion  which  followed  on  Dr.  Prewitt's  paper,  the  follow- 
ing case  of  traumatic  aneurism  of  the  internal  carotid  following  a  stab 
in  the  neck  was  related  by  Dr.  Briggs,  of  Nashville : 

A  man,  aged  twenty-three,  had  an  expansile  tumor  in  the  left  parotid 
region,  encroaching  on  the  throat,  causing  difficulty  in  swallowing. 
There  was  a  loud  bruit,  and  pulsation  in  the  swelling  was  lessened  b}' 
pressure  on  the  common  carotid.  A  small  cicatrix  pointed  to  the  re- 
ceipt of  a  stab  six  weeks  before. 

Acting  on  the  principle  that  a  traumatic  aneurism  is  simpl}^  a 
w^ounded  arter}^  and  should  be  treated  as  such,  Dr.  Briggs  performed 
the  old  operation.  A  knife  being  pushed  into  the  most  prominent 
part  of  the  swelling,  this  opening  was  plugged  with  a  finger,  which  ap- 
peared to  find  the  wound  in  the  artery.  The  opening  being  enlarged 
upwards  and  downwards,  large  clots  were  removed,  followed  by  a  gush 
of  arterial  blood,  which  was  arrested  by  stuffing  the  wound  with 
sponges.  The  incision  being  prolonged  downwards,  the  common 
carotid  was  tied.    On  the  removal  of  the  sj)onges  the  haemorrhage  was 


LIGATURE    OF    THE    INTERNAL   CAROTID.  459 

as  violent  as  before,  and  was  only  arrested  by  the  pressure  of  a  finger 
in  the  sac.  While  this  was  kept  up,  the  tissues  were  scratched  through, 
and  a  ligature  placed  above  and  below  the  opening.  Though  the  in- 
cision measured  8  inches,  there  was  scarcely  sufficient  room.  At  the 
bottom  of  the  wound  the  styloid  process  could  be  seen,  and  just  ante- 
rior and  internal  to  it  the  ligatures  on  the  internal  carotid.  The  pa- 
tient made  a  good  recover3\ 

It  will  be  seen  that  the  two  cases  of  Dr.  Prewitt  and  Dr.  Briggs  differ 
widely.  Though  both  were  traumatic,  in  one  there  was  room  to  place 
a  distal  ligature,*  in  the  other  there  was  not.  The  fact  that,  in  the 
latter,  haemorrhage  did  not  recur  for  the  twenty- five  days  in  which  the 
patient  lived  after  plugging  the  sac,  leads  one  to  hope  that  plugging 
with  aseptic  gauze,  firmly  and  carefully  against  the  base  of  the  skull, 
might  be  successful  in  such  another  case,  if  the  wound  could  be  kept 
aseptic,  and  the  dysphagia  met  by  tube-feeding. 

Line  and  Guide. — These  are  practically  the  same  as  those  given  for 
the  common  carotid.     The  internal  carotid  lies  outside  and  rather  be- 
hind the  external  carotid.   Soon  after  its  commencement  it  becomes  too 
deeply  placed  to  admit  of  ligature. 
Relations  in  the  Neck  : 

In  Front. 

Skin;  fasciae;  platysma. 

Sterno-mastoid  ;  stylo-glossus  ;  stylo-pharyngeus. 

Glosso-pharyngeal  nerve. 

Parotid  gland. 

Outside.  Inside. 

Internal  jugular.  Pharynx. 

Vagus.  Ascending  pharyngeal. 

Tonsil. 
Internal 
carotid. 

Behind, 
Rectus  capitus  anticus  major. 
Superior  laryngeal  nerve. 

Operation. — This  is  much  the  same  as  that  for  ligature  of  the  ex- 
ternal carotid.  The  artery  can  only  be  tied  in  its  first  and  more  su- 
perficial part.  It  here  lies  outside  and  rather  behind  the  external 
carotid. 

Thus  the  incision  should  be  made  along  the  anterior  border  of  the 

*  Dr.  Briggs,  in  replying  (p.  256),  said  that,  though  the  opening  in  the  internal 
carotid  was  very  close  to  the  caroti  I  canal,  not  more  than  I  inch  from  it,  the  operation 
was  not  so  very  difficult. 


460  OPERATIONS   ON    THE    HEAD   AND    NECK. 

sterno-mastoid,  and  not  just  in  front  of  it,  the  centre  of  the  incision 
lying  about  i  inch  above  the  upper  border  of  the  thyroid  cartilage. 
The  sterno-mastoid  being  defined,  and  the  cellular  tissue  opened  up 
in  front  of  it,  the  same  superficial  structures  will  be  met  with  as  in 
the  external  carotid  (p.  454).  When  the  carotids  are  found,  the  ex- 
ternal should  be  drawn  inwards,  and  the  internal  outwards,  the 
digastric  being  pulled  upwards.  The  needle  should  be  passed  from 
without  inwards,  avoiding  the  internal  jugular  and  the  vagus. 

LIGATURE  OP   THE  VERTEBRAL  ARTERY. 

Indications. 

(1)  Wounds,  (2)  Traumatic  Aneurisms,  may  be  considered  together. 
There  is  liable  to  be  much  obscurity  as  to  whether  it  is  the  vertebral 
or  some  other  artery — e.g.,  inferior  thyroid,  ascending  cervical,  common 
carotid,  or,  if  higher  up,  the  occipital  which  is  attacked,  and  further, 
when  it  is  decided  that  it  is  the  vertebral  artery,  it  is  by  no  means 
easy  to  carry  out  satisfactory  treatment.  The  best  course  is  to  enlarge 
the  wound,  and  to  decide,  with  the  finger,  the  relation  of  the  wounded 
vessel  and  of  the  ha3morrhage  to  the  transverse  processes  of  the  ver- 
tebrae. The  direction  of  the  wound,  and  the  effect  of  pressure  below 
and  above  the  level  at  which  the  vertebral  ceases  to  be  compressible 
— i.e.,  above  the  "  carotid  tubercle  "  (vide  infra) — will  also  be  helpful. 

If  the  wound  is  low  down,  there  are  between  2  and  3  inches  of  the 
artery  available  for  ligature,  and  this  should  be  placed  al)ove  and 
below  the  wound  (p.  464).  But  if,  as  is  more  frequent,  the  wound  is 
higher  up  in  the  neck,  it  will  be  almost  impossible,  even  after  exposing 
and  clipping  away  the  anterior  roots  of  the  transverse  processes,  to 
find  and  secure  the  artery,  and  the  best  course  will  be  to  plug  the 
wound,  as  successfully  done  by  Dr.  Kocher,  of  Berne.*  This  case  is 
usually  described  as  one  of  traumatic  aneurism,  but  it  is  doubtful  how 
far  this  word  should  be  applied  to  it. 

A  man,  aged  forty-eight,  had  been  stabbed  in  the  neck.  Daily 
hsemorrhages,  often  profuse,  took  place  for  three  weeks,  in  spite  of 
plugs  of  charpie  soaked  in  perchloride  of  iron.  On  admission  into 
the  hospital  a  wound  was  found  about  an  inch  to  the  left  of  the  spine, 
at  the  level  of  the  fifth  and  sixth  cervical  vertebra?.  Through  the 
wound  was  seen  a  swelling,  feebly  pulsating.  On  removing  coagulum 
and  opening  up  the  wound,  free  arterial  hsemorrhage  came  from  a 
cavity  about  the  size  of  a  small  apple,  at  the  bottom  of  which  trans- 
verse processes  could  be  felt.  The  bleeding  came  both  from  the  central 
and  peripheral  ends  of  the  artery,  between  the  transverse  processes  of 

*  Langenbeck's  Arch.f.  Klin.  Chir.,  Bd.  xii.  8.  867.  A  full  abstract  of  the  paper  is 
given  in  the  Syd.  Soc.  Bien.  Retr.,  1871-72,  p.  202. 


LIGATURE   OF   THE   VERTEBRAL    ARTERY.  461 

apparently  the  fifth  and  sixth  vertebrte.  As  a  ligature  could  not  be 
applied,  a  pea-like  bit  of  charpie,  soaked  in  solution  of  iron  perchloride, 
was  introduced  between  the  transverse  processes.  Carbolized  dress- 
ings were  applied,  and  the  head  kept  fixed  with  a  stiff  collar.  On 
removal  of  the  plug  on  the  fourth  da,y,  partly  with  a  stream  of  water, 
partly  with  forceps,  no  bleeding  followed.  The  patient  was  discharged 
cured  in  five  weeks,  having  had  a  slight  attack  of  erysipelas. 

In  the  above  paper  Maisonneuve  is  said  to  have  tied  both  the  verte- 
bral and  inferior  thyroid  arteries  and  removed  a  bullet.  The  haemor- 
rhage was  arrested,  but  death  occurred  from  purulent  infiltration  into 
the  spinal  canal.  This  appears  to  have  been  a  case  of  ligature  of  the 
artery  before  its  entrance  into  the  vertebral  canal. 

Aneurisms  of  the  vertebral  are  always  traumatic.  There  are  about 
twenty-four*  cases  on  record  of  aneurisms  and  wounds  of  this  vessel. 
The  situation  varies  much.  Usually  it  is  high  up,  near  the  mastoid 
process.f 

The  difficulty  of  diagnosis  of  wounds  of  the  vertebral  and  other  ar- 
teries, and  their  results,  have  been  already  alluded  to.  Mr.  Holmes  J 
states  that  there  are  eleven  cases  in  which  the  carotid  has  been  tied 
for  wound  or  aneurism  of  the  vertebral,  of  course  with  no  advantage. 
This  mistake  seems  to  have  arisen  from  forgetfulness  of  the  fact  that 
while  pressure  on  the  common  carotid  against  the  transverse  process 
of  the  sixth  cervical  vertebra  will  check  all  pulsation  in  the  carotid, 
the  branches  of  the  carotid,  and  aneurisms  situated  on  them,  it  will 
also  check  pulsation  in  a  vertebral  aneurism.  Mr.  Holmes  points  out 
that  the  above  "  carotid  tubercle  "  is  higher  up  than  is  usually  sup- 
posed, being  situated  2  to  3  inches  above  the  clavicle,  and  he  lays 
down  the  rule  that  when  a  traumatic  aneurism  is  situated  in  the  course 
of  the  vertebral,  and  its  pulsations  are  commanded,  however  com- 
pletely, by  pressure  on  the  common  carotid  low  in  the  neck,  it  ought 
not  to  be  treated  as  being  carotid,  or  as  affecting  a  branch  of  the 
carotid,  until  it  is  clearly  proved  that  its  pulsations  are  stopped  by 
pressure  applied  above  the  level  at  which  the  vertebral  ceases  to  be 
compressible — i.e.,  above  Chassaignac's  carotid  tubercle.  Ligature  of 
the  vertebral  artery  in  the  first  few  inches  of  its  course  being  so  very 


*  Barbieri,  of  Milan,  quoted  by  Kocher  {loc.  mpra  eit.),  has  collected  sixteen;  Pilz 
(Langenbeck's  Arch.  J.  Klin.  Chir.,  Bd.  ix.)  has  gathered  together  four.  Tlien  there 
is  Kocher's,  one  by  Liicke  in  the  same  Arch.,  Bd.  viii.  s.  78,  and  the  American  case 
given  below. 

t  In  nine,  according  to  Kocher,  the  wound  was  at  or  above  the  second  cervical  ver- 
tebra ;  in  two,  "  at  the  upper  part  of  the  neck  ;"  in  six  it  was  below  the  second  cervical 
vertebra.  In  four  of  the  latter  it  was  in  the  neighborhood  of  the  external  carotid  ar- 
tery  and  its  branches  ;  thus  in  one  the  wound  was  at  the  angle  of  the  jaw, 

X  "  Boy.  Coll,  Surg.  Lectures":  Lancet,  July  26,  1873, 


462  OPERATIONS    ON   THE    HEAD    AND    NECK. 

rarely  available,  compression  of  the  artery  low  down,  with  the  aid  of 
an  ansesthetic  if  needful,  and  with  the  additional  help  of  direct  press- 
ure or  cold  on  the  aneurism  above,  should  be  made  use  of. 

Dr.  Weir  {New  York  Archives  of  Medicine,  1884)  records  a  case  of  a 
man  stabbed  on  the  right  side  of  the  neck,  about  t  inch  below  the  ear, 
just  in  front  of  the  sterno-mastoid.  A  traumatic  aneurism,  believed 
to  be  of  the  vertebral,  slowly  developed.  Digital  pressure  over  the 
carotid  tubercle  was  made  use  of,  and  in  three  hours  the  tumor  was 
cured. 

If  pressure  fails,  and  if  the  aneurism  increases  in  size,  the  surgeon 
must  decide  between  running  the  risk  of  injecting  ergotine,  or  throwing 
in  coagulants,  or  opening  the  swelling  and  plugging  it.  In  the  latter 
case  aseptic  gauze  strips — viz.,  iodoform  or  sal  alembroth — should  be 
made  use  of  in  preference  to  the  perchloride  of  iron.  The  gauze 
should  be  carried  into  the  aneurism,  the  wound  being  opened  suffi- 
ciently freely  to  allow  the  surgeon  to  see  what  he  is  about,  and  the 
head  should  afterwards  be  kept  rigidly  still.* 

(3)  Ligature  of  the  Innominate  Artery,  either  at  the  same  time  to 
prevent  Secondar}^  Haemorrhage,  or,  later  on,  to  arrest  this  when  it 
has  occurred  at  the  seat  of  Ligature  owing  to  the  Reflux  of  Blood  from 
the  Subclavian. — This  matter  has  been  alluded  to  at  p.  478,  where  the 
case  in  which  Dr.  Smyth,  of  New  Orleans,  ligatured  the  vertebral  for 
secondary  haemorrhage  after  ligature  of  the  innominate  is  alluded  to. 

(4)  Epilepsy. — Dr.  Alexander,  of  Liverpool,  has  performed  this 
operation  in  thirty-six  cases,  after  the  first  case  usually  tying  both 
arteries  simultaneously.  The  following f  is  his  opinion  of  the  value 
of  the  operation : 

The  operation  was  performed  in  the  hope  that  a  lessened  supply  of 
blood  to  the  hinder  brain  and  spinal  cord  Avould  result  in  a  diminution 
or  cessation  of  the  epileptic  convulsions,  it  being  expected  that  the 
diminution  would  be  more  permanent  to  the  parts  supplied  after  liga- 
ture of  the  vertebrals  than  after  ligature  of  other  vessels,  on  account  of 
the  absence  of  anastomosing  branches,  and  the  restraints  to  dilatation 
of  the  unligatured  vessels  by  the  long  canals  through  which  the  vessels 
pass.  For  a  time  these  expectations  were  realized,  but  soon  relapses  oc- 
curred, and  in  May,  1884,  an  analysis  of  thirty-six  cases  showed  only 
eight  cases  which  have  had  so  few  fits  since  operation  that  they  may  be 
practically  considered  cured.  Eleven  were  for  several  months  so  much 
improved  that  they  seemed  to  be  cured ;  and,  although  the  fits  have 
recurred  in  all,  yet  the  improvement  is  still  distinctly  manifest  in 
many.     In  sixteen  cases  there  did  not  seem  to  be  any  decided  im- 

*  In  one  case  related  by  Kocher  the  nerves  lying  behind   the  artery  were  injured, 
and,  in  another,  dangerous  inflammation  of  the  spinal  meninges  took  place, 
t  Did.  of  Surg.,  vol.  ii.  p.  786. 


LIGATURE    OF   THE    VERTEBRA!.    ARTERY.  463 

provement.  Three  died  out  of  the  thirty-six — one  from  hfemorrliage, 
one  from  embolism,  and  one  from  pleurisy.  All  the  cases  operated  on 
were  chronic,  hopeless  epileptics,  many  of  whom  had  become,  gradu- 
ally, mentally  affected.  None  of  the  latter  were  permanently  bene- 
fited to  any  practical  extent.  On  account  of  the  uncertainty  as  to 
what  cases  will  derive  benefit  from  the  operation,  Dr.  Alexander  has 
ceased  to  recommend  or  perform  the  operation.  As  far  as  he  can  at 
present  see,  this  chapter  of  surgery  may  be  closed. 

Relations. — The  vertebral  artery,  the  largest  and  usually  the  first 
branch  of  the  subclavian,  arises  from  the  upper  and  back  part  of  the 
artery,  and  ascends  at  first  a  little  outwards  and  backwards  to  reach 
the  foramen  in  the  transverse  process  of  the  sixth*  cervical  vertebra. 
Traversing  these  foramina,  it  passes  through  that  of  the  axis;  it  then 
bends  outwards  and  upwards  to  reach  that  of  the  atlas,  and  then 
passing  backwards  lies  in  a  deep  groove  on  the  posterior  arch  of  the 
atlas  behind  the  articular  process,  beneath  the  sub-occipital  nerve.  In 
this  position  it  lies  in  the  sub-occipital  triangle.  Finally,  it  pierces 
the  posterior  occipito-atloid  ligament  and  dura  mater,  and  running 
upwards  and  forwards  through  the  foramen  magnum,  winds  round  to 
the  front  of  the  medulla  to  join  its  fellow  and  form  the  basilar  at  the 
lower  border  of  the  pons  Varolii. 

Behind. 

Cervical  nerves  (in  vertebral  canal). 
Sympathetic  plexus. 
Outside.  Inside. 

Scalenus  anticus  and  Longus.  colli, 

phrenic  nerve. 

Vertebral  artery. 

In  Front. 

Internal  jugular. 
Inferior  thyroid. 
Thoracic  duct  (left  side)  crossing  from  within 

outwards. 
Vertebral  vein. 
Sympathetic  plexus. 

Operation. — The  head  being  suitably  raised  and  turned  slightly 
over  to  the  opposite  side,  an  incision,  3  inches  long,  is  made  along  the 
outer  border  of  the  stern o-mastoid,  extending  to  the  clavicle.  In 
deepening  this  incision,  the  external  jugular  must  be  looked  out  for, 
running  parallel,  here,  with  the  outer  border  of  the  muscle.     When 

*  Sometimes  through  the  fifth  or  seventh. 


464  OPERATIONS    ON    THE    HEAD    AND    NECK. 

the  deep  fascia  is  divided,  the  sterno-ma&toid,  together  with  the  vein, 
is  to  be  drawn  inwards,  the  incision  being  prolonged  along  the  clavi- 
cle, and  some  of  the  clavicular  fibres  detached  from  the  bone  if  need- 
ful. The  surgeon  then,  working  with  the  narrow  point  of  a  steel 
director,  carefully  opens  up  the  deep  connective  tissue,  and  endeavors 
to  define  the  interval  between  the  scalenus  anticusand  thelongus  colli 
muscles;  as  the  outer  border  of  the  former  muscle  corresponds  with 
that  of  the  sterno-mastoid,  this  muscle  must  be  well  retracted  inwards. 
In  defining  the  vertebral  artery  as  it  lies  between  the  scalenus  and 
longus  colli,  the  presence  of  the  phrenic  nerve  lying  on  the  scalene, 
the  pleura  internally,  the  internal  jugular,  inferior  thyroid,  and  the 
vertebral  veins  over  the  vessel,  with  the  thoracic  duct  crossing  it,  on 
the  leftside,  from  within  outwards,  must  all  be  borne  in  mind,  these 
structures  being  drawn  to  either  side,  as  is  convenient,  with  strabismus 
hooks.  The  needle  is  then  passed  from  without  inwards.  Owing  to 
the  deep  position  of  the  artery,  a  good  light  is  essential,  and  the  head 
must  be  manipulated  so  as  to  relax  the  deep  parts  as  is  required. 
The  anterior  transverse  tubercle  in  the  sixth  cervical  vertebra  is  a 
good  guide  in  cases  of  difficulty  ;  below  it,  the  pulsation  of  the  artery 
should  be  felt.  In  cleaning  the  artery  previous  to  passing  the  liga- 
ture, the  fibres  of  the  sympathetic  must  be  disturbed  as  little  as  pos- 
sible. Temporary  paralysis  from  the  interference  with  these  fibres  is 
almost  certain,  and  immediate  contraction  of  the  corresponding  pupil 
is  of  very  frequent  occurrence,  and  may  be  regarded  as  a  pretty  cer- 
tain indication  that  the  vessel  has  been  secured. 

Another  method  of  securing  the  vertebral  is  by  making  incisions  as 
in  Mott's  operation  for  tying  the  innominate  (p.  480),  dividing  both 
heads  of  the  sterno-mastoid,  reflecting  these,  finding  the  carotid  sheath, 
turning  this,  together  with  the  sterno-hyoids  and  sterno-thyroids,  in- 
wards, thus  exposing  the  longus  colli,  and  so  finding  the  artery  in  the 
interval  between  this  muscle  and  the  scalenus  anticus. 

It  has  been  suggested  by  Dietrich  to  tie  the  vertebral  artery  between 
the  atlas  and  axis.  This  operation  would  prevent  the  reflux  of  blood 
from  above  after  a  wound  or  traumatic  aneurism  below  had  been 
plugged ;  but,  however  feasible  as  a  dissecting-room  operation,  it 
would  be  one  of  great  difficulty  on  the  living,  owing  to  the  depth  and 
small  part  of  the  artery  which  is  to  be  tied. 

LIGATURE  OF  SUBCLAVIAN. 

As  it  is  very  doubtful  whether  ligature  of  the  first  part  is  a  justifia- 
ble operation  even  in  these  days  of  improvements  in  aseptic  surgery 
and  of  new  ligatures,  the  operations  on  the  second  and  third  parts 
will  be  described  first,  the  two  being  taken  together,  as  one  operation 


LIGATURE   OF   THE   SUBCLAVIAN.  465 

is  often  only  an  extension  of  the  other.     The  operation  on  the  first 
part  will  then  be  more  briefly  alluded  to  (p.  475). 

LIGATURE  OF  SUBCLAVIAN  IN  ITS  SECOND  AND 
THIRD  PARTS  (Fig.  87). 

Line. — From  the  curved  and  short  course  of  this  vessel  no  definite 
line  can  be  given. 

Guide. — The  chief  point  to  remember  is  the  outer  margin  of  the 

sterno-mastoid,  as  this  corresponds  to  the  outer  border  of  the  scalenus 

anticus,  which  has  to  be  defined  and  then  traced  down  to  the  tubercle 

on  the  first  rib,  the  part  of  the  artery  to  be  tied  lying  on  the  upper 

surface  of  this  bone  outside  and  behind  the  muscle  and  the  tubercle. 

Relations  (third  part) : 

In  Front. 

Skin ;  fascia? ;  platysma ;  branches  of  cervical 
plexus. 

Venous  plexus — viz.,  external  jugular ;  supra- 
scapular ;  posterior  scapular ;  transverse 
cervical ;  branch  from  cephalic. 

Transverse  cervical  and  supra-scapular  arte- 
ries. 

Cellular  tissue  and  fat. 

Nerve  to  subclavius. 

Subclavian  vein  (below). 

Above.  Behind. 

Omo-hyoid.  Subclavian  First  rib. 

Cords  of  brachial  plexus.         (third  part.) 

Relations  (second  part) : 

In  Front. 
Skin;  fasciae;  platysma, 
Sterno-mastoid. 
Scalenus  anticus. 
Phrenic  nerve. 
Above.  Below. 

r\       ^        c  \         !,•    1  Subclavian  artery  rlcura. 

Cords  of  brachial  ^^^^^^^  part). " 

plexus. 

Behind, 
Scalenus  medius. 
Collateral  Circulation. 

When  a  Ligature  is  applied  to  the  Third  or  Second  Fart. — Three  main 
sets  of  vessels  *  are  here  employed — viz., 

*  Key,  Guy's  Hoxp.  Reports,  1836.     A  case  in  which  the  subclavian  artery  had  been 
tied  for  axillary  aneurism  twelve  years  previously, 

30 


466 


OPERATIONS   ON   THE    HEAD    AND   NECK. 


Above. 

The  supra-scapular, 
The  posterior  scapular, 

The  superior  intercostal, 
The  aortic  intercostals. 
The  internal  mammary, 
Numerous  plexiform  vessels 
passing  through  the  axilla 
from  branches  of  the  sub- 
clavian. 


with 


with 


Below. 
The    acromio-thoracic,    the 
infrascapular,     subscapu- 
lar, and  dorsalis  scapulae. 

The  long  thoracic,  and  sca- 
pular arteries. 


with        Branches  of  the  axillary. 


M^en  a  Ligature  is  applied  to  the  First  Part. — The  collateral  circula- 
tion may  be  carried  on  by  the  superior  anastomosing  with  the  inferior 
thyroid,  one  vertebral  with  its  fellow,  the  internal  mammary  and  su- 
perior intercostal  with  the  long  thoracic  and  scapular  arteries,  and  the 
princeps  cervicis  with  the  profunda  cervicis.* 

Indications. 

i.  In  some  cases  of  axillary  aneurism — i.e.,  those  in  which,  owing 
to  the  pain,  the  irritability  of  the  patient,  the  depth  of  the  artery,  the 
rapid  increase  of  the  aneurism,  pressure  is  not  available.!  With 
regard  to  the  operation  of  ligature  of  the  subclavian  for  axillary 
aneurism,  it  should  be  remembered  that  the  mortality  is  high.  Mr. 
Holmes t  thus  explains  this  fact:  In  the  first  place  the  procedure  re- 
sembles Anel's  operation  almost  as  much  as  Hunter's.  Hence  sup- 
puration of  the  sac  from  loose  formation  of  clot,  and  secondary  haem- 
orrhage from  disease  of  the  artery,  may  be  anticipated.  Again,  the 
ligature  must  be  placed  in  the  immediate  vicinity  of  large  branches. 
Then,  again,  the  deficient  formation  of  laminated  clot  is  further 
favored  by  the  absence  or  loose  structure  of  the  aneurismal  sac  and 
by  the  want  of  resistance  in  the  parts  which  surround  it.  Mr.  Erich- 
sen,§  also,  alludes  to  the  unfavorable  results  after  ligature  of  the  sub- 
clavian for  axillary  aneurism  :  i.e.,  out  of  forty-eight  cases,  twenty- 
three  were  cured  and  twenty-five  died ;  and  attributes  the  high  mor- 
tality chiefly  to  three  causes — viz.,  (1)  inflammatory  changes  within 
the  chest;  (2)  suppuration  of  the  sac;  (3)  haemorrhage.  See  below, 
p.  470,  when  the  chief  points  in  the  after  treatment  are  given. 


*  Smith  and  Walsham,  p.  38. 

t  See  the  conclusions  on  axillary  aneurism  formulated  by  Mr.  Holmes  in  his  "  Lec- 
tures at  the  College  of  Surgeons,"  p.  ]07. 
X  Syst.  of  Surg.,  vol.  iii.  p.  109. 
§  Surgery,  vol.  ii.  p.  212.. 


LIGATURE    OF   THE    SUBCLAVIAN.  467 

ii.  Cases  of  subclavian  and  subclavio-axillary  aneurism  not  amen- 
able to  other  treatment;  or  where  the  aneurism,  especially  if  subcla- 
vio-axillary, is  small  in  size  (not  larger  than  a  hen's  egg),  of  recent 
duration,  and  distinctly  traumatic  in  origin.  Mr.  Poland,*  in  his 
report  on  subclavian  aneurism,  gives  nine  cases  of  recovery  and 
twelve  cases  ending  fatally  after  ligature  of  the  second  or  third  por- 
tions of  the  subclavian  for  subclavian  or  subclavio-axillary  aneurism. 
With  regard  to  the  nine  successful  cases  Mr.  Poland  raises  a  very  im- 
portant question.  Was  the  aneurism  developed  in  a  healthy  artery  ? 
If  so,  the  success  is  explained.  In  three  the  aneurism  was  entirely 
local,  independent  of  general  arterial  disease.  In  two  this  was  doubt- 
ful. In  four  the  origin  was  spontaneous.  Whether  general  atheroma 
existed  here  must  remain  uncertain,  as  the  patients  recovered,  and  the 
artery,  where  tied,  was  healthy.  "  We  can  only  say  this,  that  sub- 
clavian aneurism  in  its  early  stage,  occurring  in  persons  of  the  early 
or  middle  period  of  life,  without  any  indication  of  disease  of  the  heart 
or  large  vessels,  may  and  does  recover,  and  that  a  cure  may  be  effected 
by  means  of  a  ligature  of  the  third  or  second  portion  of  the  artery, 
notwithstanding  the  disease  is  one  of  spontaneous  origin,  and  there- 
fore presumed  to  be  indicative  of  arterial  disease."  In  these  successful 
cases  the  size  of  the  aneurism  in  no  case  exceeded  that  of  a  hen's  egg, 
and  the  duration  of  the  cases  was  short,  being  under  four  and  a  half 
months. 

Of  the  twelve  unsuccessful  cases  of  subclavio-axillary  aneurism, 
there  was  good  reason  to  believe  that  in  ten  at  least  an  atheromatous 
condition  of  the  arteries  existed.  The  size  of  the  aneurism  was,  in  all 
the  cases  save  one,  larger  than  in  the  first  group. 

iii.  As  a  distal  operation,  together  with  ligature  of  the  common 
carotid  for  some  cases  of  aneurism  of  the  innominate  and  aorta.  See 
p.  493. 

iv.  Preparatory  to  such  operation  as  removal  of  the  scapula  (pp. 
141,  144). 

V.  For  wounds  of  the  subclavian  itself — e.g.,  stabs.  This  is  very 
rarely  called  for. 

Operation  for  Ligature  of  the  Third  or  Second  Portion 
of  the  Subclavian  ( Fig.  87). — These  two  will  be  considered  together, 
as  one  operation  is  but  an  extension  of  the  other. 

The  patient  being  turned  over  on  to  the  sound  side,  propped  up 
with  pillows  at  the  edge  of  the  table,  the  head  drawn  over  to  the 
opposite  side,  the  shoulder  on  the  side  of  the  aneurism  is  depressed 
as  strongly  as  possible,  so  as  to  open  out  the  posterior  triangle.  The 
surgeon  then,  standing  in  front  of  the  shoulder,  draws  the  skin  down 

*  Guy's  Hosp.  Reports,  1871. 


468  OPERATIONS    ON   THE    HEAD    AND    NECK. 

over  the  clavicle  with  his  left  hand,  and  makes  an  incision,  3  inches 
long,  over  this  bone  between  the  sterno-mastoid  and  trapezius,  divid- 
ing skin,  fasciae,  and  platysma.  The  soft  parts  being  now  allowed  to 
glide  up,  the  incision  should  lie  i  inch  above  the  clavicle,  the  external 
jugular  vein  thus  escaping  injury,  for  as  this  vein  perforates  the  deep 
fascia  just  above  the  clavicle,  it  cannot  be  drawn  down  with  the  skin, 
superficial  fascia,  and  platysma.  If  more  room  is  required,  owing  to 
the  elevation  of  the  clavicle  or  the  presence  of  an  aneurism,  the  above 
muscles  must  be  divided,  and  a  longitudinal  incision  made  upwards, 
at  right  angles  to  the  inner  end  of  the  first,  and  a  triangular  flap  raised 
outwards  and  upwards. 

When  the  superficial  parts  have  been  sufficiently  incised,  the  deep 
fascia  is  carefully  opened  at  the  inner  end  of  the  incision  and  laid  open 
on  a  director,  and  the  areolar  tissue  beneath,  which  varies  much  in 
density  and  the  amount  of  fat  which  it  contains,  scratched  through  in 
a  direction  aiming  for  the  outer  edge  of  the  scalenus  anticus,  which 
corresponds  to  the  outer  margin  of  the  clavicular  part  of  the  sterno- 
mastoid.  As  soon  as  the  deep  fascia  is  divided,  the  presence  of  the 
following  complications  must  be  remembered  and  provided  for.  The 
soft  tissues  may  be  much  matted,  oedematous,  and  altered  owing  to 
previous  use  of  pressure  or  inflammation  set  up  around  a  rapidly 
growing  aneurism.  The  venous  plexus  formed  by  the  external  jugular 
receiving  the  supra-scapular  and  transverse  cervical  veins,  and  often 
the  posterior  scapular  and  a  branch  over  the  clavicle  from  the  cephalic 
as  well,  may  be  much  engorged.  Any  one  or  more  of  these  veins 
which  are  in  the  way  should  be  drawn  aside  with  a  strabismus  hook 
or  aneurism  needle,  or  divided  between  two  chromic  catgut  ligatures. 
Owing  to  the  free  anastomoses,  this  latter  course  is  to  be  adopted 
without  hesitation  if  needful.  It  cannot  be  insisted  upon  too  strongly 
that  a  bloodless  wound  will  best  enable  the  surgeon  to  reach  this  often 
most  difficult  artery,  and  a  bloodless  wound  is  best  secured  by  tying 
beforehand  every  vein  which  cannot  be  drawn  out  of  the  way,  and  by 
using  a  fine-pointed  steel  director  as  much  as  possible  after  the  deep 
fascia  is  opened. 

As  a  rule  the  transverse  cervical  artery  is  above  the  incision,  and 
the  supra-scapular  below  it,  under  the  clavicle,  but  occasionally  one 
or  both  of  these  may  be  found  lying  across  the  field  of  operation,  and 
must  then  be  drawn  aside  with  a  strabismus  hook.  While  the  veins 
may  be  ligatured  without  hesitation,  the  arteries  must  be  preserved 
intact,  that  the  collateral  circulation  may  not  be  interfered  with  (p. 
466). 

The  position  of  the  omo-hyoid  is  altogether  inconstant,  and  may  be 
neglected. 

The  outer  edge  of  the  scalenus  anticus  being  defined  by  scratching 


LIGATURE    OF    THE   SUBCLAVIAX.  469, 

through  the  cellular  tissue,  this  muscle  is  to  be  traced  downwards  to 
the  scalene  tubercle  on  the  first  rib,  immediately  above  and  behind 
which  landmark  lies  the  artery.  One  of  the  lowest  cords  of  the  bra- 
chial plexus  will  now  come  into  view,  and  must  not  be  mistaken  for 
the  artery,  a  contingency  otherwise  not  unlikely  to  happen,  as  the 
lowest  cord  is  in  close  contact  with  the  artery,  and  ma}'  receive  pulsa- 
tion from  it.*  A  little  cleaning  will  show  the  fasciculation  of  the 
nerve,  while  the  artery  is  closer  to  the  rib,  and  is  flat,  not  rounded, 
when  rolled  under  the  finger.f  By  compressing  the  artery  between 
the  needle  passed  beneath  it  and  his  forefinger,  and  noting  the  result 
of  this  pressure  on  the  aneurism  and  the  pulse  below,  the  surgeon  will 
clear  up  any  doubts  as  to  whether  he  has  the  artery  or  no. 

The  position  of  the  artery  being  made  sure  of,  the  sheath  |  is  opened 
Avith  the  point  of  the  knife,  the  artery  cleaned,  and  the  needle  passed 
from  above  downwards  and  from  behind  forwards.  This  best  avoids 
the  worst  risk — i.e.,  of  including  a  nerve  cord.  The  needle  should  be 
kept  most  carefully  close  to  the  vessel,  and  not  dipped  suddenly  or 
used  with  any  force;  otherwise  the  pleura  or  subclavian  vein  may  be 
injured.§ 

The  artery,  before  the  ligature  is  tightened,  will  be  inspected  with 
some  anxiety  as  to  its  condition — whether  normal  in  size  and  struct- 
ure, or  if  dilated,  thickened,  or  thinned. ||    If  much  alteration  is  found, 

*  Mistaking  a  cord  for  tlie  artery,  or  tying  the  two  together,  has  happened  to 
excellent  surgeons.  Thus,  in  a  case  under  the  care  of  Mr.  Green,  of  St.  Thomas's  Hos- 
pital, one  of  the  cords  was  included  in  the  ligature.  The  agony  produced  was  extreme  ; 
the  man  did  not  cry  out,  but  the  expression  of  his  face  was  something  most  appalling. 
The  ligature  was  immediately  loosed,  and  the  artery  aione  tied,  and  all  the  frightful 
symptoms  disappeared.  The  man  made  a  good  recovery,  and  was  seen  many  years 
afterwards  perfectly  well  (Poland,  loc.  supra  cit.,  p.  83). 

t  Another  fallacy  about  the  pulsation  is  its  variableness.  Sometimes  it  is  violent 
and  excited  ;  at  others,  as  in  the  case  of  a  dilated  and  diseased  artery,  or  one  much 
handled  in  the  operation,  almost  imperceptible. 

X  A  process  of  deep  cervical  fascia  which  tlie  vessel  brings  out  from  between  the 
scaleni,  and  one  vviiich  varies  much  in  density. 

I  The  surgeon  should  be  provided  wiih  needles  of  different  curves  and  a  silver  probe 
with  a  large  eye.  As  pointed  out  by  Sir  W.  Fergusson  {Surgery,  p.  607)  with  his 
attention  to  details  in  operations,  the  eye  of  the  needle  should  always  be  close  to  the 
point,  that  the  ligature  may  be  at  once  seized  with  forceps  as  soon  as  it  appears  under 
the  vessel,  the  difBculties  at  this  stage  of  the  operation  being  not  only  the  surrounding 
parts  of  importance,  but  also  the  fact  that  in  tliis  case  the  handle  cannot  be  depressed 
as  freelv  as  in  operations  on  most  other  arteries,  and  thus  it  is  difficult  to  make  the 
point  rise  above  the  vessel. 

II  In  a  case  of  Liston's  the  vessel  was  dilated,  thick,  and  soft,  "aiilly  enough  com- 
pared to  the  finger  of  a  buckskin  glove."  The  patient,  aged  forty-three,  died  of  haemor- 
rhage on  the  fourteenth  day.  In  a  patient  of  M.  Jobert's  (Poland,  loc.  mpra  cit.,  p. 
110)  "  the  vessel  was  found  enormously  large,  equal  to  the  size  of  an  aorta  ;  it  was  9 
lines  in  diameter  throughout,  pulsation  being  very  marked." 


470  OPERATIONS    ON    THE    HEAD    AND    NECK. 

the  surgeon  should  carefully  divide  the  outer  half  of  the  scalenus 
anticus  on  a  director  with  a  blunt-pointed  bistoury,  sponging  the 
wound  absolutely  dry  so  as  to  watch  for  the  phrenic  nerve,  which,  if 
seen,  should  be  drawn  inwards  with  a  strabismus  hook. 

If  the  artery  is  found  diseased  here  also,  the  surgeon  should  use  a 
flat  ligature  of  ox  aorta  or  kangaroo-tail  tendon,  and  endeavor  so  to 
adjust  the  tightening  of  the  ligature  as  not  to  divide  both  the  internal 
and  middle  coats  (p.  482). 

In  cases  where  the  wound  is  a  very  deep  one,  care  must  be  taken 
while  making  the  second  knot  that  the  first  does  not  slip.  The  liga- 
ture having  been  tightened  and  cut  short,  drainage  is  provided  and 
the  wound  carefully  closed  and  dressed.  The  limb  is  then  bandaged 
with  cotton-wool  and  kept  somewhat  supported,  and  the  temperature 
maintained  with  hot  bottles  if  needful. 

The  Chief  Points  in  the  After-treatment  are — {i.)  keeping 
the  wound  rigidly  aseptic,  (ii.J  meeting  haemorrhage,  (iii.)  meeting 
suppuration  of  the  sac,  (iv.)  combating  the  stiffness  and  weakness  of 
the  limb  which  sometimes  follows  on  ligature  of  the  main  trunk. 

(i.)  This  need  not  be  further  alluded  to  in  a  work  like  this,  but  it 
cannot  be  too  strongly  insisted  upon  that,  if  the  high  mortality  (p. 
466)  which  has  hitherto  attended  this  operation  is  to  be  reduced,  it 
is  iTiainly  to  keeping  the  wound  aseptic  throughout,  and  thus  to  early 
primary  union  that  we  must  look. 

(ii.)  The  risk  of  hgemorrhage  is  so  great  that  the  surgeon  should 
always  endeavor  to  j^revent  it  by  trying  to  obtain  early  and  firm 
closure  of  the  wound  as  just  indicated,  and  by  keeping  the  patient 
absolutely  quiet  till  all  is  soundly  healed.  When  once  haemorrhage 
occurs,  the  outlook  is  very  grave.  The  treatment  must  vary  according 
to  the  size  of  the  wound  which  remains.  If  there  be  only  a  sinus,  firm 
pressure  must  be  made  over  the  dressings  by  well-adjusted  bandaging, 
aided  by  a  heavy  bag  of  shot  or  a  truss-like  instrument  adjusted  for 
the  purpose.* 

If  the  wound  is  larger,  and  perhaps  septic  and  sloughy,  an  anaes- 
thetic should  be  given,  and,  any  clots  being  removed,  the  wound 
should  be  gently  but  thoroughly  swabbed  over  with  a  solution  of  zinc- 
chloride  (gr.  20  or  40  to  water  |j),  the  wound  then  dried,  dusted  with 
iodoform,  and  pressure  applied  as  above ;  or  the  wound  may  be 
plugged  with  strips  of  one  of  the  antiseptic  gauzes,  or  with  sponges 
of  appropriate  size  and  texture  which  have  been  kept  in  a  solution  of 
carbolic  acid  (1  in  40),  and  are  now  wrung  dry  and  dusted  with  iodo- 
form, silk  being  attached  to  the  deeper  ones  before  they  are  inserted. 


*  In  a  large  hospital,  where  relays  of  assistants  are  available,  digital  pressure  may 
be  made  use  of. 


LIGATURE    OF    THE   SUBCLAVIAN.  471 

The  patient  should  be  kept  as  quiet  as  possible  with  morphia ;  the  diet 
should  be  restricted  and  given  at  regular  intervals,  and  without  stim- 
ulants unless  absolutely  required.  The  cases  collected  by  Mr.  Poland* 
show  that,  while  haemorrhage  may  occur  as  early  as  the  eighth  day, 
it  may  be  deferred  till  the  twenty-sixth  or  forty-sixth  day,  the  ligature 
having  come  away  on  the  twentieth  day  in  either  case.  In  neither  of 
these  two  latter  cases  had  the  wound  healed :  in  the  first  the  patient 
had  been  allowed  to  get  up ;  in  the  second,  pyaemia  was  present. 

The  same  writer  f  thus  sums  up  the  sources  of  haemorrhage  after 
ligature  of  the  third  and  second  portions  of  the  subclavian  : 

(a)  From  the  sac,  either  primary  from  puncture  in  the  operation,  or 
secondary  from  ulceration  or  rupture  at  an  early  period,  or  later  after 
inflammation  and  suppuration  and  giving  way  of  the  sac. 

(6)  From  the  ligatured  part,  in  consequence  of  non-obliteration  of  the 
artery  when  the  ligature  is  becoming  detached,  the  haemorrhage  being 
generally  from  the  peripheral  end  of  the  artery  tied.  It  may  be  due 
also  to  an  unsound  state  of  the  coats  of  the  artery,  such  as  dilated, 
thinned  coats  or  atheromatous  degeneration. 

It  is  worth  remembering  that  this  haemorrhage  is,  in  excei^tional  cases, 
recovered  from.  Mr,  Poland  %  quotes  four  cases  from  the  collection  of 
Kocher  which  recovered  after  the  use  of  styptics,  pressure,  and  cold, 
and  adds  one  under  the  care  of  Sir  W.  Fergusson,§  in  which  the 
haemorrhage  was  arrested  promptly  and  for  good  by  pressure  applied 
immediately  by  the  patient's  wife. 

(iii.)  Suppuration  of  the  sac.  The  frequency  of  this  untoward 
accident  has  been  already  alluded  to  (p.  466).  It  is  due  to  the  close 
proximity  of  the  ligature  to  the  sac,  without  any  intervening  branch,, 
whereby  the  necessary  coagulum  is  but  ill-formed  and  loose,  acting  as; 
a  foreign  body,  and  setting  up  irritation,  inflammation,  and  its  con- 
sequences. 

Every  endeavor  should  be  made  to  prevent  its  occurrence  by  for- 
bidding all  handling  of  the  aneurism. 

If  evidence  of  it  occur,  and  the  swelling,  which  has  at  first  dimin- 
ished in  size,  again  about  the  second  or  third  week  steadily  increasing 
in  size,  becomes  tense  and  painful,  but  without  pulsation,  it  must  be 
opened  by  a  sufficiently  free  incision,  carefully  emptied  of  pus  and 
clots,  drained,  and  well-adjusted  pressure  applied.  If  the  wound  has 
not  healed,  and  particularly  if  it  has  become  septic,  haemorrhage  is 
extremely  likely  to  occur  after  opening  the  sac — an  ominous  compli- 

*  Loc.  supra  cit.,  pp.  116,  117. 

f  Loc.  supra  cit.,  p.  125. 

X  Loc.  supra  cit ,  p.  1 27. 

^   Edin.  Med.  and  Sury.  Juurn,  1831,  p.  399. 


472  OPERATIONS   ON    THE    HEAD   AND   NECK. 

cation,  which  can  only  be  met  by  plugging  with  aseptic  sponge  or 
gauze,  and  using  firm  pressure  (p.  470). 

(iv.)  Atrophy,  stiffness  and  weakness  of  the  limb.  These  must  be 
met  by  warmth,  use  of  electricity,  and,  above  all,  by  pcrseveringly 
used  massage. 

The  condition  which  is  so  common  in  the  lower  extremity  after  an 
analogous  operation  (see  Ligature  of  External  Iliac),  in  which  the 
limb  long  remains  in  a  state  not  far  removed  from  gangrene,  is  much 
less  common  in  the  upper  extremity. 

Difficulties  and  Accidents  which  may  be  met  with,  and 
Points  to  avoid,  during  the  Operation. 

1.  Sterno-mastoid  and  trapezius  well  developed  along  the  clavicle. 

2.  A  short  full  neck  with  much  fat  both  above  and  beneath  the 
deep  fascia. 

3.  Clavicle  much  pushed  up.  This  may  be  due  to  the  way  in  which 
the  patient  has  carried  his  shoulder  to  relieve  the  painful  pressure  on 
the  brachial  plexus,  or  to  the  presence  of  an  aneurism. 

4.  The  artery  may  be  displaced.  This  deviation  from  its  usual 
course  may  be  acquired,  as  in  a  case  of  Warren's  *  where  the  left  sub- 
clavian was  raised  and  displaced  by  a  curvature  of  the  spine  in  a 
woman  aged  thirty,  the  subject  of  an  aneurism  (attributed  to  strain), 
about  the  size  of  a  pigeon's  egg,  just  above  the  scapular  end  of  the 
clavicle.  Ligature  was  performed  by  an  incision  made  obliquely  from 
the  outer  edge  of  the  sterno-mastoid  towards  the  acromio-clavicular 
joint,  the  pulsation  of  the  artery  being  the  guide.  Congenital  devia- 
tions which  have  been  met  with  are  the  artery  perforating  the  scalenus 
anticus,  or  lying  in  front  of  it,  or,  as  usual,  behind  this  muscle,  but 
now  closely  accompanied  by  its  vein. 

5.  The  soft  parts  infiltrated,  oedematous,  or  matted  together  owing 
to  the  presence  and  irritation  of  an  aneurism,  aided,  perhaps,  by  pre- 
vious attempts  at  cure  by  pressure. 

6.  Great  engorgement  of  the  veins  met  with  here,  due  to  the  presence 
of  an  aneurism  and  increased  by  the  anesthetic. 

7.  Aneurismal  sac  very  prominent  and  liable  to  be  punctured  in  the 
operation.  This  accident  took  place  even  in  the  hands  of  the  elder 
Travers.  The  sac  was  as  large  as  a  swan's  egg,  and  pulsating  strongly. 
The  patient  died  on  the  third  day  after  the  operation  with  effusion  into 
the  right  pleura.  The  ligature  was  firmly  seated  on  the  artery  at  the  root 
of  the  sac  and  adjoining  the  outer  edge  of  the  scalenus.  The  sac  had 
a  pouch-like  enlargement  upwards,  which  closely  overlaid  the  artery 
on  the  pectoral  side ;  and  this,  having  been  penetrated  in  the  passage 
of  the  needle,  had  occasioned  the  profuse  arterial  haemorrhage  without 

*  Quoted  by  Poland  [loc.  supra  cit.,  p.  77). 


LIGATURE    OF    THE    SUBCLAVIAN.  473 

saltus,  which  was  not  arrested  by  the  tightening  of  the  ligature,  and 
which  was  only  controlled  by  introducing  a  sponge  tent  into  the  wound. 
The  same  accident  is  stated  by  Mr.  Erichsen  to  have  happened  to  Cusack 
while  ligaturing  the  subclavian  for  a  diffused  aneurism  of  the  axillary 
artery,  though  this  can  scarcely  be  correctly  called  a  wound  of  the  sac. 
The  alarming  gush  of  blood  which  took  place  was  arrested  by  plug- 
ging the  wound,  but  the  haemorrhage  recurred  fatally  on  the  tenth  day. 

8.  Wound  of  the  supra-scapular  artery  necessitating  ligature  of  this 
branch.  As  a  rule  this  artery  lies  too  low  down  to  be  injured — a  com- 
plication to  be  extremely  deprecated,  as  it  is  one  of  the  chief  channels 
by  which  the  collateral  circulation  is  established  (p.  465).  In  about 
one  out  of  every  three  cases  the  posterior  scapular  will  be  found  to 
arise  from  the  third  part  of  the  subclavian  as  a  separate  branch. 
Erichsen*  advises,  if  this  condition  be  met  with,  that  the  ligature  be 
applied  as  far  as  possible  "to  the  proximal  side  of  the  branch.  If 
necessity  obliges  the  ligature  to  be  applied  close  to  the  branch,  it  is 
perhaps  safer  to  tie  this  also,  as  the  anastomosis  of  vessels  in  this  region 
is  so  abundant  that  the  risk  of  gangrene  from  the  obliteration  of  a 
single  branch  would  be  very  small."  But,  according  to  the  post- 
mortem examination  of  a  case  in  which  Mr.  Key  had  tied  the  artery 
twelve  years  previously  for  axillary  aneurism,  the  posterior  as  well  as 
the  supra-scapular  are  very  important  channels  by  which  the  blood 
is  carried  into  the  axillary  through  the  infra-scapular  {Guy^s  Hosp.  Re- 
ports, 1836). 

Any  artery  crossing  the  subclavian  should  be,  normally,  the  trans- 
verse cervical.  This  or  any  other  vessel  which  may  be  an  artery 
should  always  be  drawn  aside  with  a  strabismus  hook. 

9.  Pulsation  in  the  artery,  weak  or  deficient,  or,  on  the  other  hand, 
excited  and  tumultuous  (p.  469). 

10.  Including  a  cord  of  the  brachial  plexus  (p.  469). 

11.  Injuring  the  pleura.  This  has  happened  on  several  occasions 
during  the  passage  of  the  needle  round  the  artery,  owing  to  the  close 
proximity  of  the  serous  membrane  to  the  vessel,  and  the  difficulty  in 
passing  the  needle,  especially  when  the  clavicle  is  much  raised,  ren- 
dering it  impossible  to  pass  the  needle  from  below,  and  thus  away 
from,  the  pleura. 

Erichsen  t  considers  inflammation  of  the  contents  of  the  thorax  to 
be  the  most  frequent  cause  of  death,  proving  fatal  in  1  out  of  every 
2.5  cases.  This  is  not  pytemic,  but  arises  from  causes  essentially  con- 
nected either  with  the  operation  or  with  the  aneurism  itself.  "  These 
are  referable  to  three  heads.  (1)  Septic  inflammation  of  the  deep 
areolar  tissue  at  the  root  of  the  neck  may  extend  to  the  anterior  medi- 

*  Surgery,  vol.  ii.  p.  208.  t  Loc.  supra  cit.,  vol.  ii.  p.  212. 


474  OPERATIONS    ON   THE    HEAD    AND    NECK. 

astinum,  the  pleura,  and  pericardium."  ....  "(2)  The  sac  may,  by 
its  pressure  inwards,  encroach  upon,  and  give  rise  to  inflammation  of, 
that  portion  of  the  pleura  which  corresponds  to  its  posterior  aspect. 
This  occurred  in  a  case  in  which  Mayo,  of  Winchester,  operated,  and 
is  more  liable  to  happen  if  suppuration  have  taken  place  in  the  sac; 
when  this  occurs,  adhesion  may  take  jDlace  between  this  and  the 
pleura,  or  even  the  tissue  of  the  adjacent  lung,  and  the  contents  of  the 
suppurating  tumor  may  be  discharged  into  the  pleural  cavity  or  air- 
tubes,  and  so  coughed  up.  Of  this  curious  mode  of  termination  there 
are  at  least  two  cases  on  record — one  by  Bullen,  in  which  the  patient 
recovered ;  the  other  by  Gross,  in  which  the  patient  died  from  the 
escape  of  the  contents  of  the  sac  into  the  cavity  of  the  pleura.  (3) 
Division  of  the  phrenic  nerve  would  necessarily,  by  interfering  with 
the  respiratory  movements,  induce  a  tendency  to  congestion  and 
inflammation  of  the  lungs,  and  although  such  an  accident  must  be  a 
very  rare  one  in  cases  of  ligature  of  the  subclavian  for  axillary  aneu- 
rism, yet  it  undoubtedly  has  occurred,  as  I  have  myself  witnessed  in 
one  case." 

12.  Injuring  or  including  the  nerve  to  the  subclavius  in  the  ligature. 
This  nerve,  derived  from  the  junction  of  the  fifth  and  sixth  cervical, 
usually  gives  a  filament  to  the  phrenic.  If,  as  occasionally  happens, 
this  filament  is  replaced  by  a  nerve  constituting  an  important  part  of 
the  origin  of  the  phrenic,  injury  to  it  will  be  followed  by  urgent  and 
speedily  fatal  dyspnoea. 

13.  Injury  to  the  subclavian  vein.  This  is  rare,  as  the  vein  lies 
below  and  well  away  from  the  artery.  But  if  ligature  was  called  for 
in  a  case  in  which  the  vein  accompanied  the  artery  between  the  sca- 
lenes,  this  deviation  would  prove  embarrassing. 

I  have  spoken  at  p.  470  of  division  of  the  scalenus  anticus  if  the 
surgeon  does  not  find  the  part  of  the  artery  beyond  this  muscle 
healthy.  It  is  not  needful  to  speak  at  length  and  separately  of  this 
step,  as  it  is  a  mere  extension  of  the  operation  for  ligature  of  the  third 
part,  the  muscle  being  also  only  divided  in  part.  Mr.  Poland  *  points 
out  that,  of  eight  cases  in  which  the  scalenus  was  partially  divided, 
five  recovered,  and  that  of  these  five  recoveries  the  operation  was  on 
the  left  side.  These  cases  thus  fully  prove  that  a  ligature  may  be 
placed  on  the  second  part  of  the  artery  without  fear  of  want  of  throm- 
bus formation  or  of  injury  to  important  parts.f 

*  Loc.  supra  cit.,  p.  128. 

t  As  shown  by  Mr.  Poland  {loc.  supra  cit.,  p.  129),  the  i-emarks  of  Porter  are  scarcely 
borne  ont  on  the  numerous  and  great  perils  of  this  operation — viz.,  the  phrenic  nerve 
on  the  scalenus  anticus ;  the  thoracic  duct  lying,  on  the  left  side,  at  the  inner  edge 
of  the  muscle;  the  fact  that  three  large  branches  are  usually  given  off  by  the  subcla- 
vian while  it  is  between  the  scaleni ;  and  the  close  proximity  of  tlie  first  dorsal  nerve 
behind  the  artery. 


LIGATURE   OF   THE   SUBCLAVIAN.  475 

LIGATURE  OF  THE  FIRST  PART  OF  THE  SUB- 

CLAVIAN.=^= 

As  this  operation  has  been  performed  by  surgeons  of  the  highest 
eminence,  and  as  it  affords  good  practice  on  the  dead  subject,  it  will 
be  given  here.  It  seems  most  doubtful,  however,  Avhether  the  im- 
provements of  modern  surgery  aided  by  recently  introduced  ligatures 
will  ever  render  this  a  successful  operation,  failing,  as  these  advantages 
almost  certainly  will,  to  meet  that  secondary  haemorrhage  which  has 
proved  so  fatal  from  the  distal  side  of  the  ligature,  owing  to  the  facility 
with  which  the  numerous  collaterals  bring  in  blood  to  this  spot. 

Mr.  Erichsen,  who  gives  what  he  calls  an  "  appalling  "  table  of  four- 
teen cases,  all  fatal,  condemns  the  operation  as  "  bad  in  principle  " 
and  "  most  unfortunate  in  practice,"  and  considers  that  it  should  "be 
banished  from  surgical  practice." 

Relations. — These,  owing  to  the  greater  depth  of  the  artery  on  the 
left  side,  must  be  given  separately. 

In  Front. 
Skin ;  fascice. 

Sterno-mastoid  ;  sterno-hyoid  ;  sterno-thyroid. 
Internal  jugular  and  (often)  vertebral  vein. 
Vagus;  phrenic;  cardiac  nerves. 

Kiglit  subclavian  (first  part). 

Behind. 

Recurrent  laryngeal;  sympathetic. 
Longus  colli ;  pleura  (and  beneath). 

In  Front. 
Sterno-mastoid  ;  sterno-hyoid  ;  sterno-thyroid. 
Pleura;  lung. 

Vagus ;  phrenic ;  cardiac  nerves. 
Internal  jugular ;  innominate  veins. 
Common  carotid. 
Outside.  Inside. 

Pleura.  Trachea. 

Left  subclavian  Qilsophagus;  thoracic 

(first  part).  ^uct. 

Behind. 

Sympathetic. 

CEsophagus ;  thoracic  duct. 

Longus  colli. 

*  These  remarks  refer  to  the  right  subclavian.  A  ligature  has  certainly  once  been 
placed  on  the  first  part  of  the  vessel  on  the  left  side,  Dr.  Rodgers,  of  New  York  being 


476  OPERATIONS    ON    THE    HEAD    AND    NECK. 

Operation. — This  resembles  ligature  of  the  innominate.  The  fol- 
lowing account  is  taken  from  Mr.  Barwell  :* 

A  triangular  flap  having  been  turned  upwards  and  outwards,  and 
both  heads  of  the  sterno-mastoids  divided,  the  anterior  and,  if  need- 
ful, the  external  jugular  veins  are  secured  with  double  chromic-gut 
ligatures,  and  cut.  The  fascia  over  the  sterno-hyoid  being  exposed, 
"  the  director,  after  a  little  opening  in  the  aponeurosis  has  been  made, 
can  be  insinuated  behind  that  muscle,  which  also  must  be  severed. 
It  is  well  now  to  look  and  feel  for  the  carotid  artery  before  going  on 
to  divide  the  sterno-thyroid,  whose  outer  edge  covers  that  vessel,  and 
never,  as  far  as  my  experience  of  the  dead  subject  goes,  conceals  the 
subclavian."t  The  finger  of  the  operator,  after  division  of  the  sterno- 
hyoid, readily  detects  the  longitudinal  course  and  pulsation  of  the 
carotid,  and  may  with  ease  push  the  edge  of  the  sterno-thyroid  from 
off  its  sheath  inward,  in  which  position  the  muscle  should  be  held 
with  a  blunt  hook.  When  thus  the  sheath  of  the  vessel  is  brought 
into  view,  the  operator  should  look  for  the  large  veins  that  always, 
but  more  especially  if  there  have  been  dyspnrea,  overlie  it.  Choosing 
a  vacant  spot,  he  merely  nicks  the  loose  structure  in  which  they  lie, 
and  then  pushes  them  up  and  down,  tearihg  the  cellular  tissue  a  little, 
till  the  dense  fibrous  sheath  is  bared  sufficiently — first,  to  have  a  small 
opening  made  in  it,  and  then  to  be  slit  up.  This  should  be  done  on 
the  front  and  inner  aspect.  Now,  at  this  part,  the  vein  diverges  a  little 
from  the  artery,  so  as  to  leave  a  triangular  interval,  through  which 
the  vagus  runs.  A  blunt  hook  is  placed  over  this,  and  it  is  to  be 
drawn  with  the  jugular  vein  gently  outward.  The  next  point  is  to 
find  the  subclavian.  To  do  this  the  operator  must  remember  that  the 
usual  description  and  delineation  of  the  innominate  bifurcation  is  in- 
correct. It  is  generally  depicted  as  if  the  two  branches  rose  side  by 
side  and  almost  at  right  angles  to  each  other.  In  reality,  the  subcla- 
vian springs  behind  the  carotid,  and  the  angle  between  the  two  vessels 
is  very  acute.  Therefore,  to  detect  the  subclavian,  the  operator  must 
place  his  finger  at  the  back  and  outer  part  of  the  carotid,  when, 
passing  it  down,  he  comes,  generally  a  few  lines  above  the  clavicle,  to 
the  slightly  divergent  pulsating  line  of  the  subclavian,  which  lies 
deeper  than  the  carotid  by  the  wdiole  diameter  of  that  vessel. 

the  operator,  and  losing  his  patient  from  haemorrhage  on  the  fourteenth  day.  Mr. 
Erichsen  {loc.  supra  cit.)  states  that  Sir  A.  Cooper  failed  in  an  attempt  to  secure  the 
vessel,  and  that  he  is  said  to  have  wonnded  the  thoracic  duct.  See  also  Mr.  Banks's 
remarks,  p.  539. 

*  Intern.  Enryd.  Surg ,  vol.  iii.  p.  513. 

f  "  The  mere  division  of  the  muscle  is  in  itself  unimportant,  but  there  lies  behind 
it  a  plexus  of  large  veins  passing  from  the  thyroid  body  to  the  internal  jugular,  gen- 
erally distended  by  the  dyspnoea  accompanying  aneurism  at  the  root  of  the  neck. 
Tlieir  division  causes  profuse  bleeding  and  subsequent  difficulty  in  recognizing  the 
deeper  parts." 


LIGATURE    OF   THE    IKNOMINATE.  477 

In  selecting  the  spot  for  placing  the  ligature,  it  is  well  not  to  put  it 
quite  close  to  the  bifurcation,  but  also  not  too  near  the  border  of  the 
scaleni,  lest  the  recurrent  laryngeal  or  the  phrenic  should  be  injured. 
The  vagus  and  the  jugular  vein  should  be  kept,  not  too  forcibly,  out- 
wards, and  the  needle  should  be  passed  from  below,  while  with  his 
left  forefinger  the  surgeon  gently  presses  the  pleura  downward  and 
outward.  Some  obstruction  behind  the  artery  will  very  likely  be 
encountered,  but  it  is  better  gently  and  patiently  to  overcome  this,  and 
never  on  any  account  to  attempt  to  pass  the  needle  the  other  way  ;  for 
if  this  be  attempted,  the  point  of  the  instrument  is  certain  to  penetrate 
the  pleura.  Having  now  passed  and  tied  the  ligature,  the  surgeon 
should  consider  the  advisability  of  also  securing  the  vertebral.  It  lies 
in  the  groove  between  the  longus  colli  and  scalenus,  so  that  the  jugu- 
lar vein  must  now  be  held  inwards ;  the  dissection  already  made  will 
have  so  nearly  exposed  the  artery  that  a  few  touches  with  a  director 
will  lay  it  sufficiently  bare  to  allow  the  passage  of  the  needle.  The 
position  of  the  phrenic  nerve  on  the  anterior  scalene,  outside  and  a 
good  deal  in  front  of  the  vessel,  guards  it  against  much  risk  of  injury, 
but  still  it  must  be  carefully  avoided.  The  operator  must  not  mistake 
the  inferior  thyroid  (which  is,  however,  much  smaller,  and  usually  at 
this  part  external)  for  the  vertebral*  itself. 

LIGATURE  OF  THE  INNOMINATE  (Figs.  87,  90). 

Owing  to  the  fatality  of  this  operation,  the  question  arises  whether 
it  is  justifiable  or  no.  There  have  certainly  been  eighteen  cases,  and 
in  only  twof  have  the  jDatients  survived. 

The  extreme  danger  of  the  operation  is  due  partly  to  difficulties 
which  may  be  met  with  at  the  time  of  its  performance — difficulties 
which  have  driven  most  skilful  surgeons  to  abandon  the  operation — 
but  chiefly  to  the  frequency  of  secondary  ha?morrhage. 

In  an  operation  which  must  be  performed  at  so  long  intervals  it 
will  be  some  time  yet  before  we  know  how  far  modern  antiseptic 
surgery  is  able  to  diminish  the  above  mortality,  with  the  absence  or 
diminution  of  suppuration,  the  more  rapid  healing,  the  firmer  throm- 
bosis, and  the  improved  ligatures.  Sir  J.  Lister,  speaking  of  antisep- 
tic ligatures  in  1869,  wrote  thus  sanguinely  :  "  For  my  own  part,  I 
should  now  without  hesitation  undertake  ligature  of  the  innominate, 

*  "  In  certain  cases  the  aneurisraal  sac  overlying  the  vertebral  artery  renders  it  inac- 
cessible." 

t  One  of  these  is  the  well-known  case  of  Dr.  Smyth,  of  New  Orleans  {Sycl.  Soc, 
Bien.  Retr.,  1865-66,  p.  346).  The  other,  under  the  care  of  Mr.  Mitchell  Banks,  has 
never  been  published.  I  am  enabled,  through  his  courtesy,  to  give  this  case  below,  p. 
484.  Another  case  has  been  briefly  published  by  Prof.  Durante,  of  Rome  {Lancet, 
1887,  vol.  i.  p.  876),  before  the  wound  was  soundly  healed.  If  the  termination  of  this 
case  has  been  published,  it  has  escaped  me. 


478  OPERATIONS    ON    THE    HEAD    AND    NECK. 

believing  that  it  would  prove  a  very  safe  procedure."  Two  cases  have 
recently  been  fully  reported — viz.,  Mr.  Thomson's  and  Mr.  Bennet 
May's.  In  spite  of  all  the  care  taken,  and  the  use  of  modern  ligatures, 
neither  case  ended  successfully.  Mr.  Thomson's  case  died  on  the 
forty-second  day,  of  hemorrhage,  which  began  on  the  thirtieth  day. 
It  was  believed  that  the  sinus  which  resulted  from  the  drainage-tube 
became  seiDtic,  and  that  the  pulse  had  ulcerated  into  the  innominate 
at  a  point  quite  unconnected  with  the  ligature,  the  latter,  ox  aorta 
furnished  by  Mr.  Barwell,  having  disappeared.  Mr.  May's  case  died 
of  secondary  hsemorrhage  on  the  nineteenth  day,  caused  by  the  large 
and  very  hard  kngt,  which  had  been  tied  in  the  ligature  used,  ulcer- 
ating into  the  vessel  (p.  483). 

At  the  present  time,  till  we  have  further  evidence  bearing  on  the 
influence  of  modern  surgery  on  this  operation,  we  may  say  that  there 
are  cases  which  are  clearly  most  inappropriate,  and  that  there  are  cer- 
tain special  precautions  which  should  not  be  neglected  during  and 
after  the  operation. 

First,  as  to  selection  of  cases,  the  following  words  of  Mr.  Holmes* 
should  be  remembered.  The  operation  ''should  never  be  performed, 
however,  unless  the  artery  can  clearly  be  felt  healthy  behind  the 
sterno-clayicular  jointjt  or  the  tumor  is  so  plainly  limited  as  to  afford 
a  very  reasonable  hope  that  it  will  be  found  so.  In  cases  of  tubular 
enlargement  of  a  long  tract  of  artery  in  the  neck,  it  is  more  than  use- 
less to  expose  an  artery  which  will  probably  be  found  so  diseased  as 
either  to  prevent  the  operator  from  the  attempt  to  tie  it,  or  to  give  way 
and  occasion  fatal  bleeding  within  a  few  hours  if  it  be  tied."| 

The  folloAving  are  amongst  the  precautions  indicated  : 

1.  Rigid  antiseptic  precautions  persevered  with  till  the  wound  is 
soundly  closed. 

2.  Use  of  a  flat  ligature  in  securing  the  innominate — viz.,  one  of 
ox  aorta  or  kangaroo  tail — with  care,  if  possible,  that  the  knot  is  not  a 
hard  one  and  does  not  press  strongly  on  the  side  towards  the  artery. 

3.  Securing  the  carotid  artery  at  the  same  time,§  and  the  vertebral 
either  then  or  a  few  days  later. 

*  Syst.  of  Surg.,  vol.  iii.  p.  112. 

t  As  Mr.  Holmes  remarks  in  a  foot-note,  "  If  the  shape  of  the  bones  or  joints  is 
altered,  it  is  clear  that  the  aneurism  arises  in  the  thorax." 

J  It  is,  however,  very  remarkable  that  in  the  cases  of  Porter  and  Aston  Key, 
though  it  was  found  impracticable  and  undesirable  to  ligature  the  artery  owing  to  its 
diseased  and  dilated  condition,  such  changes  were  set  up  in  the  vessel  by  the  exposure 
and  manipulation  as  to  lead  to  gradual  cessation  of  the  pulsation  in  the  aneurism  in 
one  case  and  its  diminution  in  the  other. 

?  Ligature  of  the  common  carotid  at  the  same  time  as  the  innominate  will  not  nec- 
essarily prevent  hsfimorrhage,  as  was  shown  by  Smyth's  case,  in  which  the  carotid 
was  tied  at  the  same  time  as  the  innominate.     Hsemorrhage  occurred  on  the  fourteenth 


LIGATURE    OF    THE    INNOMINATE.  479 

4.  Closing  the  wound  as  thoroughly  as  possible,  so  as  to  prevent 
formation  and  collection  of  discharges. 

Mr.  Thomson,  in  his  exhaustive  account  of  his  own  case,  states 
his  belief  that  the  fatal  ulceration  into  the  innominate  was  brought 
about  by  decomposition  of  discharges  collecting  at  the  bottom  of  the 
sinus  left  by  the  drainage-tube.  This  decomposition  was,  he  thinks, 
due  to  the  difficulty  of  keeping  the  dressings  firmly  on  a  movable 
part  like  the  neck,  to  the  fact  that  the  skin  heals  much  more  quickly 
than  the  deep  parts,  and  that  the  clavicle  assists  in  preventing  the  soft 
parts  coming  together.  He  would,  in  future,  use  carefully  adjusted 
sponges  and  shot  bags  over  them. 

5.  Keeping  the  patient  absolutely  at  rest  till  the  wound  is  soundly 
healed,  morphia  being  used  subcutaneously,  and  any  tendency  to 
cough  checked  at  once  if  possible. 

Line  and  Guide. — The  vessel,  1  to  2  inches  long,  extends  along  a 
line  drawn  from  the  middle  of  the  junction  of  the  first  with  the 
secontl  bones  of  the  sternum  to  the  right  sterno-clavicular  joint  (Hol- 
den).     Its  point  of  bifurcation  varies  somewhat. 

Relations  :  In  Front. 

Sternum  ;  sterno-h^^oid  ;  sterno-thyroid. 

Left  innominate  and  right  inferior  thyroid  vein. 

Inferior  cervical  branch  of  right  vagus. 

Outside.  Inside. 

Right  innominate  vein.  Left  carotid. 

Right  vagus. 
Pleura.  Innominate  artery. 

Behind. 
Trachea. 

Collateral  Circulation. — These  are  thus  given  by  Sir  W.  Mac- 
Cormac  (Ligature  of  Arteries,  p.  75) : 

Cardiac  Side.  Distal  Side. 

First  aortic  intercostal,  with     Superior  intercostal  of  sub- 

clavian. 

Upper  aortic  intercostals,  with  Thoracic  branches  of  axil- 
r^  lary  and   intercostals  of 

internal  mammary. 

Phrenic,  with     Musculo-phrenic  of  internal 

mammary. 

Deep  epigastric,  with     Superior  epigastric  of    in- 

ternal mammary. 

day,  and  was  repeated  at  intervals.     The  vertebral   was  ligatured  on  ;lie  fifty-fourth 
day,  and  recovery  ultimately  took  place. 


480 


OPERATIONS    ON    THE    HEAD    AND    NECK. 


Free  communication  of  vertebrals  and  internal  carotids  of  opposite 
sides  inside  the  skull.  Communication  of  branches  of  opposite  ex- 
ternal carotids  in  the  middle  line  of  the  face  and  neck. 

Operation  (Figs.  87,  90). — The  patient,  having  been  brought  into 
as  satisfactory  a  condition  as  possible  by  preparatory  treatment,  the 
head,  body,  and  arm  are  placed  as  in  ligature  of  the  subclavian  (p. 
467).  The  surgeon,  standing  in  front,  makes  an  incision*  along  the 
inner  third  of  the  clavicle,  and  another  along  the  anterior  border  of 
the  sterno-mastoid,  meeting  the  first  at  an  acute  angle,  each  incision 

Fig.  90. 


Above,  the  two  heads  of  the  sterno-mastoid,  the  sterno-hyoid  and  stemo-thyroid  are  seen  re- 
flected. Two  inferior  thyroid  veins  cross  the  innominate.  Another  large  vein  is  drawn  down 
by  the  strabismus  hook. 

being  upwards  of  3  inches  long.  The  flap  thus  marked  out  is  dis- 
sected up,  the  sternal  and  clavicular  heads  of  the  sterno-mastoid  di- 
vided, and  the  sterno-hyoids  and  sterno-thyroids  are  carefully  cut 
through  on  a  director.  During  these  preliminary  steps,  one  or  two 
small  arteries  may  be  divided  and  some  enlarged  veins  connected 
with  the  inferior  thyroids  drawn  aside  or  tied  with  double  ligatures, 
and,  in  reflecting  the  above-mentioned  flap,  the  presence  of  the  ante- 
rior jugular  passing  outwards  beneath  the  sterno-mastoid  just  above 
the  clavicle  must  be  remembered. 


*  This  incision  was  made  use  of  by  Mott  when  he  tied  the  artery  in  1818.     It  ap- 
pears preferable,  as  giving  much  more  room,  to  any  other. 


LIGATURE   OF   THE    INNOMINATE.  481 

The  above  muscles,  when  cut,  being  carefully  held  out  of  the  way 
and  a  layer  of  deep  cervical  fascia  varying  in  strength  divided,  the 
pulsation  of  the  carotid  is  defined,  and  its  sheath  opened  to  the  inner 
side  and  as  low  down  as  possible. 

Other  guides  will  be  found,  in  the  trachea  and  the  subclavian,  to 
lead  the  finger  down  to  the  innominate,  the  horizontal  incision  being 
prolq^iged  a  little  internally  or  externally  as  the  case  may  need. 

The  carotid  being  traced  down,  the  innominate  will  be  found  bifur- 
cating into  the  carotid  and  subclavian  (Fig.  90).  It  is  now  that  the 
real  difficulties  may  be  met  with.  (1)  Owing  to  engorgement  of  the 
venous  circulation,  increased  by  the  ansesthetic,  the  internal  jugular 
and  innominate  vein  may  be  so  much  enlarged  as  to  protrude  into  the 
wound.  (2)  An  aneurism  may  have  reached  under  the  artery  and 
flattened  it  out  so  as  to  make  it  difficult  of  recognition.  The  cellular 
tissue  around  the  vessel  and  between  it  and  the  sternum  may  be  so 
matted  with  adhesions  as  to  make  it  difficult  to  define  the  artery  and 
its  important  relations  on  the  right  side — viz.,  vagus,  pleura,  and  right 
innominate  vein.  (3)  The  artery' itself  may  be  enormously  diseased 
and  expanded. 

In  tracing  down  the  innominate  itself,  the  surgeon  must  keep  his 
steel  director  most  carefully  on  the  front  of  the  artery.  In  following 
the  vessel  down  behind  the  sternum  in  order  to  find  a  site  for  his 
ligature,  he  will  be  aided  by  slightly  flexing  the  head  and  by  a  laryn- 
geal mirror.  The  cleaning  the  artery  must  be  done  with  the  utmost 
caution,  especially  on  the  outer  side,  owing  to  the  important  struc- 
tures lying  there ;  of  these  the  innominate  vein  and  the  vagus  may  be 
drawn  outside,  but  it  is  only  by  keeping  the  director  or  needle-point 
very  close  to  the  artery  here  that  injury  to  the  pleura  can  be  avoided. 

If  there  is  doubt  as  to  the  position  of  the  artery,  pressure  with  the 
finger  behind  the  vessel  against  the  sternum  will  arrest  the  j)ulsation 
in  the  carotid  and  the  aneurism. 

The  needle  should  be  passed  from  without  inwards  and  a  little  from 
below  upwards  to  avoid  the  pleura.  In  this  case,  as  in  that  of  the 
subclavian  and  other  deep-seated  arteries,  the  surgeon  will  do  well  to 
provide  himself  with  needles  of  different  curves,  or  with  a  silver  probe 
sufficiently  flexible  to  take  any  curve  and  with  a  large  eye  close  to  the 
point  (p.  469). 

The  question  now  arises  what  ligature  is  best  suited  to  a  large 
trunk  like  this,  with  blood  forcibly  impelled  i^ito  it  by  the  closely  ad- 
jacent heart,  and  with  collateral  circulation  certain  to  be  set  up 
quickly  along  the  carotid  and  vertebral.  This  point  is  at  present  un- 
settled. It  is  probable  that  stout  silk  or  chromic  gut,  though  properly 
prepared  and  used  with  every  antiseptic  precaution,  will  be  inefficient. 
For  in  so  large  a  vessel  very  considerable  force  will  be  required  to 

31 


482  OPERATIONS    ON    THE    HEAD    AND    NECK. 

close  it  and  stop  its  current,  the  artery  offering  much  resistance  and 
its  pulsation  being  very  strong;  thus  it  is  probable  that  any  round 
ligature  Avill  have  to  be  applied  so  tightly  as  to  divide  the  two  inner 
coats  and  thus  weaken,  probably  fatally,  an  artery  which  has  to  bear 
the  strain  of  such  strong  pulsation  before  the  wound  can  heal  and  the 
parts  consolidate  around  the  ligature. 

On  the  other  hand,  the  value  of  the  more  recently  introduced  ani- 
mal ligatures — viz.,  ox-aorta,  kangaroo-tail,  or  whale  tendon — though 
probably  superior,  is  not  yet  established.  It  is  probable  that  there  is 
much  less  risk  of  their  dividing  the  two  inner  coats,  and  there  is  every 
reason  to  expect  that,  if  properly  prepared,  their  contact  with  the  soft 
tissues  they  surround  will  be  harmless  and  unirritating  ;  that,  infil- 
trated by  wandering  cells,  they  will  be  gradually  absorbed,  new  rings 
of  fibrous  tissue  forming  in  their  place.*  But  as  yet  we  do  not  know 
whether  all  these  ligatures  are  free  from  a  tendedcy  to  slip  prema- 
turely, from  the  knot  becoming  soft  or  united.  Again,  as  pointed  out 
by  Mr.  Heath,  though  these  ligatures  are  flat  before  appHcation,  we 
are  by  no  means  safe  in  assuming  that,  as  the  ligature  is  tightened, 
there  is  no  flat  edge  pressing  in  against  the  vessel.  While,  if  there  be 
a  greater  demand  for  these  ligatures,  they  will  no  doubt  be  prepared 
in  a  reliable  form,  at  present  the  surgeon  must  be  prepared  for  the  fol- 
lowing accident,  which  happened  to  Mr.  May. 

The  needle — an  old-fashioned  silver  one,  flexible,  well  rounded  at 
the  point,  and  with  a  large  eye— having  been  passed  satisfactorily 
round  the  vessel,  "  was  threaded  with  a  small  cord,  to  which  a  strip  of 
ox-aorta  material,  kindly  sent  me  by  Mr.  Barwell,  was  attached,  and 
by  it  pulled  through.  In  tightening  the  tape,  I  had  to  draw  the  ends 
with  very  considerable  force  to  stop  the  pulsation,  the  vessel  offering 
great  resistance  and  pulsating  with  great  force.  Just  at  the  critical 
moment,  however,  the  material  gave  way  and  broke  across,  and  a  sec- 
ond piece  introduced  in  a  similar  manner  suffered  the  same  fate.  I 
then  endeavored  to  imitate  the  principle  of  the  flat  ligature  by  using 
a  cord  made  up  of  five  or  six  medium-sized  threads  of  catgut.  This 
bore  the  strain  very  well,  and,  after  tightening  with  sufficient  force  to 
completely  stop  pvilsation  in  the  tumor  and  branches  of  the  carotid,  I 
drew  on  the  ends  still  further  to  allow  of  some  subsequent  relaxation 
in  fixing  the  knot.  At  the  same  time  I  endeavored  to  avoid  crushing 
the  coats  of  the  artery.  The  ligature  was  secured  with  a  third  knot, 
and  cut  short."  The  patient  died  of  haemorrhage  on  the  seventeenth 
day,  and  it  was  found  that  this  very  precaution,  taken  with  all  care 
and  thoughtfulness  by  Mr.  May,  had  tended  to  bring  about  the  fatal 
result.     "  The  ligature  still  retained  a  firm  hold  on  the  vessel ;  one  or 


*  See  the  case  of  ligature  of  the  innominate  and  first  part  of  the  subclavian  by  Mr. 
Banks  (p.  484). 


LIGATURE    OF   THE    INNOMINATE.  483 

two  of  the  threads  were  partially  absorbed  and  softened,  but  others 
scarcely  changed.  The  knot,  unfortunately  very  large  and  hard,  was 
quite  unaltered.  Under  the  knot,  in  the  front  of  the  vessel  and  in  the 
line  of  a  fold  or  bend  of  its  wall,  was  the  obvious  source  of  the  haem- 
orrhage, in  the  form  of  a  ragged  hole  about  the  size  of  a  small  pea  ; 
this  opened  into  the  vessel  on  both  sides  of  the  ligature."  Mr.  May 
goes  on  to  say  that  the  further  appearances  were  instructive  in  view  of 
the  debatable  questions  surrounding  the  use  of  animal  ligatures.  .  .  . 
With  the  exception  of  the  hole  corresponding  to  the  knot,  no  part 
of  the  arterial  wall  was  injured  or  divided,  though  under  the  ligature 
itself  the  wall  was  thinner  than  elsewhere.  The  inner  coats  were  in- 
tact. It  was  obvious  that  the  small  chink  which  remained, between 
the  crumpled-up  folds  of  the  vessel,  the  remainder  being  occluded  by 
adhesion  of  the  inner  coats,  was  closed  by  a  moderately  firm  clot.  A 
similar  clot  with  conical  end  extended  along  the  distal  side  of  the 
artery  nearly  to  its  bifurcation.  On  the  heart  side  there  was  a  thin 
diaphragm  of  clot  with  a  conical  end,  but  it  extended  a  very  inconsid- 
erable distance.  As  the  bulk  of  the  haemorrhage  no  doubt  occurred 
here,  some  of  the  clot  may  have  got  carried  out  during  life.  The  hole 
in  the  wall  of  the  artery  having  been  closed,  it  was  shown,  by  injecting 
water,  that  the  vessel  was  wholly  occluded  at  the  seat  of  ligature. 

The  ligature  being  tied  and  cut  short,  the  surgeon  will  have  to 
decide  whether  he  will  be  satisfied  Avith  tying  the  main  trunk,  or 
whether  he  will  place  ligatures  on  other  vessels  also — e.g.^  upon  the 
carotid  and  vertebral — in  order  to  prevent  the  risk  of  that  secondary 
ha?morrhage  which  has  almost  invariably  taken  place  on  the  distal 
side  of  the  ligature  owing  to  the  facility  with  which  blood  is  brought 
into  the  branches  of  the  subclavian  through  reflux  currents  along  the 
vertebral,  common  carotid,  inferior  thyroid,  etc. 

Until  further  use  of  the  flat  animal  ligatures  has  shown  how  far  we 
can  rely  upon  these,  and  their  effect  upon  the  vessel  so  far  to  strengthen 
it  as  to  prevent  its  giving  way,  it  will  be  wiser  to  secure  the  common 
carotid,  and  also  the  vertebral  by  an  extension  outwards  of  the  hori- 
zontal incision  if  needed,  and  finding  these  vessels  by  the  steps  given 
at  pp.  441,463. 

These  vessels  being  tied,  the  Avound  is  carefully  cleaned  and  dried, 
haemorrhage  most  scrupulously  stopped,  a  drainage-tube  inserted, and 
the  wound  carefully  closed.  If  the  patient  will  bear  it,  the  limb,  pre- 
viously wrapped  in  cotton-wool,  should  be  secured  to  the  side  and 
chest,  and  every  attempt  made,  by  elastic  bandaging  and  aid  of  a  shot- 
bag,  to  keep  the  dressings  firmly  in  place,  and  thus  promote,  from  the 
first,  steady  adjustment  of  the  parts  and  sound  healing.  Morphia 
should  be  used  as  freely  as  is  safe,  to  diminish,  as  far  as  possible,  the 
sensibility  of  the  patient  to  the  irksomeness  of  his  position.     The- 


484  OPERATIONS    ON   THE    HEAD    AND    NECK. 

slightest  tendency  to  cough  should  be  treated  at  once.  The  absolute 
need  of  rest  and  quiet  should  be  enforced  upon  the  patient  until  the 
wound  is  soundly  healed. 

While  these  sheets  are  passing  through  the  press,  I  am  enabled, 
through  the  courtesy  of  Mr.  Banks,  to  give  an  abstract  of  a  most  in- 
teresting case  of  right  subclavian  aneurism,  in  which  the  innominate 
and,  subsequently,  the  first  part  of  the  subclavian  were  tied.  Owing 
to  the  exceeding  rareness  of  recovery  after  ligature  of  the  innominate, 
and  the  survival  of  a  patient  for  thirty-six  days  after  the  placing  of  a 
ligature  round  the  first  part  of  his  subclavian,  it  is  to  be  hoped  that 
this  most  instructive  case  will  soon  be  published  in  extenso. 

J.  B.,  aged  fifty,  was  admitted  into  the  Liverpool  Royal  Infirmary, 
February  10,  1883,  with  well-marked  symptoms  of  aneurism  of  the 
third  part  of  the  right  subclavian.  Attempts  to  treat  the  patient  by 
rest,  etc.,  having  failed,  owing  to  his  obstinately  persisting  in  getting  up, 
the  innominate  and  common  carotid  were  tied,  February  26,  with  the 
strictest  antiseptic  precautions.  The  earlier  steps  presented  nothing 
remarkable.  "  Unluckily,  the  bifurcation  was  quite  J  inch  lower  than 
it  ought  normally  to  be,  and  this  caused  some  difficulty  in  getting 
the  aneurism  needle  round  the  vessel.  I  used  a  needle  of  the  ordi- 
nary kind,  having  a  large  curve,  and  threaded  with  silk.  There  was 
about  a  minute  of  rather  anxious  work  while  the  needle  was  being 
tickled  through  the  tissues  surrounding  the  vessel,  a  proceeding  which 
was  accomplished  solely  by  feeling,  as  the  artery  lay  too  deep  for  me  to 
see  anything  that  could  aid  me.  By  means  of  the  silk  thread,  a  stout 
kangaroo  tendon  ligature  was  pulled  beneath  the  vessel,  then  tightened, 
three  knots  being  placed  upon  it.  I  applied  the  amount  of  force 
which  I  thought  would  be  necessary  completely  to  occlude  the  arter}^ 
but  not  to  damage  its  coats,  and  I  felt  very  certain  that  I  had  made  a 
thorough  and  satisfactory  ligature  of  the  artery.     Whether  I  really 

did  so  or  not  is  a  question The  aneurism  ceased  to  pulsate.     I 

next  proceeded  to  pass  a  ligature  round  the  common  carotid 

Being  engrossed  in  this,  I  took  no  further  notice  of  the  aneurism.  But 
those  who  were  assisting  saw  that,  after  an  interval  of  about  two  min- 
utes, a  certain  amount  of  pulsation  returned  in  the  aneurism.  I 
imagined  that  this  must  have  arisen  from  the  retrograde  circulation 
along  the  common  carotid  and  subclavian,  and  so  proceeded  at  once 
to  tighten  the  ligature  (another  kangaroo  tendon)  round  the  former 
vessel.  As  soon  as  this  was  done,  the  pulsation  in  the  aneurism  again 
became  practically  imperceptible." 

A  slight  return  of  pulsation  was  noticed  in  the  evening  of  the 
operation. 

The  restlessness  and  irritability  of  the  patient  during  the  first  few 
days  were  frightful.  He  tossed  about  the  bed,  moved  his  arm  as  much 
as  the  bandages  would  allow,  loudly  demanded  stimulants,  and  swore 


LIGATURE   OF   THE    INNOMINATE.  485 

at  everybody  about  him.  He  was  not,  however,  in  the  least  feverish 
or  delirious.  Practically  there  was  never  any  suppuration,  and  the 
extensive  wound  healed  by  primary  union.  All  dressings  were  dis- 
continued on  the  thirteenth  daj',  and  the  patient,  who  had  insisted 
on  getting  up  on  the  ninth,  went  out  on  the  twentieth  day  with  the 
wound  sound. 

Unhappily,  the  pulsation  feebly  present  in  the  aneurism  on  the 
evening  of  the  operation  l)ecarae  strong  and  accompanied  with  thrill 
by  the  third  day.  Pressure  with  a  bag  of  shot  was  tried,  but  the 
patient,  by  his  unruly  behavior,  did  all  he  could  to  prevent  any  con- 
solidation occurring.  When  the  patient  went  out  the  aneurism  was 
quite  as  soft,  and  the  pulsation  and  thrill  quite  as  obvious  as  before. 
It  very  soon  decidedly  increased,  spreading  out  under  cover  of  the 
trapezius  and  pushing  inwards  the  scalenus  anticus.  "At  the  end  of 
five  weeks  it  became  clear  that  either  the  aneurism  must  be  left  alone 
and  the  man  abandoned  to  his  fate,  or  that  something  more  must  be 
done.  But  what  ?  Galvano-puncture  and  the  introduction  of  wire 
or  other  material  into  the  sac  have  not  proved  of  sufficient  utility  to 
entitle  them  to  be  considered  satisfactory  methods  of  treatment  at  the 
present  moment,  whatever  may  become  of  them  in  the  future.  Liga- 
ture of  the  first  part  of  the  axillary  on  the  distal  side  of  the  tumor  is 
not  any  better.  To  lay  open  the  aneurism  and  attempt  to  secure  the 
artery  on  either  side  of  the  aneurismal  opening  would  almost  certainly 
have  been  fatal  on  the  spot.  To  go  down  through  the  old  cicatrix  in 
search  of  the  innominate,  with  a  view  of  tying  it  a  second  time, 
seemed  very  impracticable.  Besides,  I  could  not  be  any  more  certain 
of  curing  the  aneurism  the  second  time  than  the  first.  The  only  thing 
that  remained  was  to  tie  the  first  part  of  the  subclavian.  Sixty-seven 
days  after  the  ligature  of  the  innominate  I  performed  this  operation, 
not  using  the  spray  during  the  dissection,  lest  it  should  obscure  one's 
vision,  but  turning  it  into  the  wound  after  the  vessel  was  tied.  By 
this  date  the  tumor  had  so  increased  in  size  that  there  was  just  room 
on  its  inner  side,  and  no  more,  to  get  at  the  artery.  An  incision  was 
made  along  the  hinder  margin  of  the  sterno-mastoid,  and  another  ex- 
tending from  it  outwards  along  the  clavicle.  After  getting  through 
the  superficial  structures,  the  clavicular  portion  of  the  sterno-mastoid 
was  divided,  and  the  internal  jugular  was  followed  down  to  its  junc- 
tion with  the  subclavian.  Here,  in  consequence  of  the  matting 
together  of  parts  as  a  result  of  the  first  operation,  it  became  almost 
impossible  to  know  what  one  was  dealing  with,  and  an  unpleasant 
accident  occurred.  I  tore  across  a  vein  of  some  size  close  to  the  ])oint 
'where  it  entered  the  angle  of  junction  of  the  jugular  and  subclavian. 
Instantly  a  rushing  and  hissing  noise  showed  that  some  air  had  got 
into  the  venous  trunks,  and  for  a  brief  space  the  situation  was  uncora- 


486  OPERATIONS   ON   THE    HEAD    AND    NECK. 

fortable.  A  finger  was  put  on  the  aperture,  and  to  our  relief  the 
patient  showed  no  signs  of  being  in  any  way  aff"ected  by  the  occur- 
rence. The  aneurism  covered  by  the  thin  fibres  of  the  scalenus  anticus 
next  came  into  view.  My  colleague,  Mr.  Harrison,  gently  but  steadily 
pushed  this  outwards  with  a  couple  of  fingers,  and  in  the  ver}^  limited 
space  between  tliis  and  the  internal  jugular  I  proceeded  to  search  for 
the  artery,  guided  by  its  pulsation.  Very  slowly,  and  after  an  infinity 
of  anxious  picking  and  teasing  (for  one  dared  not  use  a  knife),  this 
was  exposed  about  ?  inch  from  the  aneurism.  The  vessel  was  obvi- 
ously thinned  and  dilated,  and  this  added  immensely  to  the  danger 
of  passing  the  aneurism  needle  beneath  it.  The  needle  was  threaded 
with  a  silk  ligature,  which  drew  after  it  a  double  catgut  ligature.  The 
loop  of  this  being  divided,  the  artery  was  secured  by  both  portions 
lying  side  by  side.  The  knots  were  drawn  very  gently,  with  the  in- 
tention of  merely  closing  the  artery  and  not  of  injuring  any  of  its 
coats.     The  aneurism  at  once  became  still. 

"A  very  few  lines  have  sufficed  to  describe  this  operation,  but  it 
took  more  than  an  hour  to  perform,  while  the  difficulty,  danger,  and 
anxiety  that  attended  it  are  almost  impossible  to  describe.  Owing  to 
the  fact  that  the  parts  had  already  been  interfered  with,  there  was  a 
great  deal  of  thickened  and  cicatricial  tissue  jiresent.  Cutting  this 
was  out  of  the  question,  as  it  was  impossible  to  say  what  was  adherent 
to  or  mixed  up  with  it.  It  had,  therefore,  to  be  pulled  asunder  fibre  by 
fibre,  with  the  aid  of  strong  forceps  and  a  dissecting  tool.  As  the 
operation  advanced,  the  depth  at  which  one  had  to  work  became 
greater  and  greater,  while,  in  order  clearly  to  make  out  the  various 
structures,  the  wound  had  to  be  kept  absolutely  free  from  blood. 
Sometimes  minutes  would  be  lost  in  picking  up  some  trifling  vessel 
from  which  just  enough  blood  would  keep  welling  to  obscure  the 
wound.  The  space  in  which  anything  could  be  done  was  of  the  most 
limited  description,  and  surrounded  by  dangers  on  every  hand.  To 
the  outer  side  was  the  bulging  aneurism,  to  the  inner  was  the  internal 
jugular,  below  lay  the  subclavian  vein,  and  immediately  beneath  the 

artery  itself  was  the  pleura Compared  with  this  performance, 

tying  the  innominate  was  a  mere  surgical  amusement,  and  I  should 
never  care  to  repeat  it  again." 

The  patient  rallied  well  from  the  operation,  but  a  few  days  later 
developed  an  attack  of  broncho-pneumonia,  which  exhausted  him  ex- 
tremely. He  slowly  rallied  from  this,  but  the  wound  gaped  widely. 
It  ultimately  healed,  save  for  a  sinus,  which  admitted  a  probe  deeply. 
On  the  twenty-third  day  the  patient  got  up,  and  by  the  thirty-first 
day  had  been  out  in  the  open  air.  On  the  evening  of  this  day  haem- 
orrhage occurred  from  the  sinus,  frequent  recurrences  took  place,  and 
the  patient  died  on  the  thirty-seventh  day  after  the  operation.     By 


LIGATURE    OF   THE   INNOMINATE.  487 

the  fourth  day  the  aneurism  had  no  trace  of  pulsation,  and  was  small 
and  hard.* 

Causes  of  Death  after  the  Operation,— It  may  be  expected 
that  most  of  these  will,  with  antiseptic  precautions,  disappear,  viz. : 

1.  Suppurative  cellulitis  and  mediastinitis. 

2.  Lung  trouble — e.g.,  bronchitis,  pleuro-pneumonia. 

3.  Pericarditis. 

There  still  remains  the  terrible  complication  of  secondary  haemor- 
rhage, which  has  occurred,  as  yet,  in  almost  every  case,  and  has  always 
proved  fatal,  save  in  the  case  of  Dr.  Smyth. 

Secondar}^  hanuorrhage  may  occur  up  to  the  sixtieth  day,  as  in 
Graefe's.  It  has  already  been  discussed  how  far  modern  surger}-  is 
likely  to  prevent  this,  and  certain  precautions  have  been  enumerated 
at  p.  478.  The  treatment  as  shown  is  mainly  preventive.  When  once 
bleeding  has  occurred,  little  can  be  done  beyond  tying  the  vertebral 
and  common  carotid,  if  this  has  not  already  been  done,  and  plugging 
the  wound  with  antiseptic  gauze  (iodoform  or  sal  alembroth),  and 
putting  on  pressure  with  shot-bags. 

On  the  frequency  of  this  complication  the  following  remarks  by 
Dr.  Sabine  are  of  interest : 

"  The  source  of  haemorrhage  and  consequent  failure  is  obvious.  It 
came  from  the  distal  side  of  the  ligature,  and  especially  from  the  sub- 
clavian  In  the  majority  of  cases  the  artery  is  not  more  than  H 

inch  between  its  origin  and  point  of  bifurcation.  What,  now,  could 
be  supposed  to  be  the  result  of  ligature  of  an  arter}^  so  short,  and  at 
the  same  time  situated  so  near  two  currents  of  blood — viz.,  that  through 
the  aorta,  and  that  which  would  pass  from  the  carotid  into  the  sub- 
clavian ?  Fatal  haemorrhage,  either  from  the  distal  or  proximal  side 
of  the  ligature,  according  to  its  seat.  If  the  ligature  be  placed  near 
the  origin,  it  would  be  impossible  for  a  clot  to  form  on  its  proximal 
side,  owing  to  the  full  current  of  blood  passing  through  the  aorta, 
though  there  might  be  one  on  the  distal  side.  On  the  other  hand,  if  it 
were  placed  near  the  point  of  bifurcation,  though  a  clot  would  in  all 
probability  be  formed  on  the  proximal  side,  as  hapiDcned  in  three  of 
the  cases  already  cited,  and  nearly  in  a  fourth,  none  would  be  formed 
on  the  distal  side,  more  especially  in  the  subclavian,  for  in  two  of  the 
cases,  and  nearly  in  three,  the  carotid  was  obliterated 

"  The  third  place  where  a  ligature  might  be  placed  is  midway 
between  the  point  of  origin  and  that  of  bifurcation.  In  this  case  there 
would  be  a  very  great  chance  of  neither  a  proximal  nor  a  distal  clot 
being  formed.  It  allows  only  2  to  J  inch  on  either  side  of  the  liga- 
ture, a  space  too  small  to  render  the  formation  of  clots  at  all  probable 

*  The  notes  of  this  case  contained  no  mention  of  an  autopsy. 


488  OPERATIONS    ON    THE    HEAD    AND    NECK. 

in  an  artery  as  large  as  the  innominate.  It  is  thus  seen  that,  in  what- 
ever situation  a  ligature  be  placed,  secondary  haemorrhage  will  almost 
inevitably  occur,  and  probably  from  the  distal  side,  because  a  ligature 
could  not,  without  very  great  difficulty,  be  applied  much  below  the 
bifurcation,  and  hence  there  would  be  sufficient  space  for  a  proximal, 
but  not  for  a  distal,  clot." 

SURGICAL  INTERFERENCE  IN   ANEURISMS   OF   THE 
INNOMINATE  AND  AORTA. 

In  spite  of  the  amount  of  work  done  in  this  direction,  the  question 
how  far  any  surgical  interference  is  justifiable  remains  unsettled.  The 
importance  of  the  subject,  the  difficulties  with  which  it  is  beset,  justify 
an  allusion  to  it  in  this  place,  it  being  understood  that  the  question 
of  surgical  treatment  only  arises  either  when  a  sufficient  trial  of  med- 
ical treatment  has  failed,  or  when  the  time  for  this  has  gone  by,  and 
the  distress  of  the  patient  justifies  resort  to  uncertain  operations  in 
the  hope  of  giving  relief  rather  than  of  bringing  about  a  cure. 

The  advisability  of  resorting  to  surgical  means  will  be  considered 
under  the  heads  of — A.  Diagnosis  ;  B.  Treatment,  the  latter  including 
— (i.)  Ligature;  (ii.)  Introduction  of  Foreign  Bodies;  (iii.)  Galvano- 
puncture. 

A.  Diagnosis  between  Innominate  and  Aortic  Aneu- 
risms.— It  is  well  known  how  extremely  difficult  this  matter  is ;  the 
expression  of  a  confident  opinion  is,  too  often,  quite  out  of  the  ques- 
tion (p.  490).  While  a  precise  diagnosis  is  usually  impossible,  no 
pains  should  be  spared  in  going  into  all  those  points  which  may  help 
in  deciding  how  far  the  aneurism  is  probably  limited  to  the  innomi- 
nate or  to  the  aorta,  and,  in  the  case  of  this  vessel,  which  piece  of  the 
arch  is  chiefly  encroached  upon,  for  it  is  only  by  paying  attention  to 
the  above  points  that  answers  can  be  given  to  the  two  questions  which 
arise — viz.  (1)  Is  any  operation  justifiable  at  all?  (2)  If  an  operation 
is  justifiable,  what  is  it  to  be  ? 

Chief  Points  to  pay  Attention  to  in  Diagnosis. 

1.  The  Position  of  the  Aneurism. — This  is  obviously  only  of  value  in 
a  few  cases,  when  the  patient  is  seen  early,  or  when  he  can  be  relied 
upon  for  an  intelligent  history  of  his  case.  Mr.  Wardrop's  rule  was, 
that  innominate  aneurism  first  presents  itself  to  the  inner  side  of  the 
right  sterno-mastoid,  carotid  aneurism  in  the  interval  between  the  two 
heads,  and  a  subclavian  one  to  the  outer  side  of  the  muscle.  Mr. 
Barwell*  writes  of  the  first  of  the  above  thus:  "The  tumor  of  an 
innominate  aneurism  generally  occupies  the  episternal  notch,  but 
chiefly  on  the  right  side,  and,  even  though  it  may  not  rise  high,  takes 

*  Intern.  Encycl.  Surg.,  vol.  iii.  p.  507. 


SUEGICAL   INTERFERENCE    IN    THORACIC   ANEURISMS.  489 

up  the  whole  breadth  of  this  space.  On  gently  pressing  the  finger 
backward  and  downward,  the  rounded  margin  of  the  sac  can  be  felt. 
After  a  little  time  the  sternal  end  of  the  clavicle  protrudes  abnormally, 
and  partakes  in  the  pulsation  (communicated),  while  the  sternal  and, 
afterwards,  the  clavicular  portion  of  the  sterno-mastoid  are  also  pushed 
forward.  Not  unfrequently  the  first  costal  cartilage,  outside  where  it 
joins  the  sternum,  is  also  abnormally  prominent,  and  throbs  with  the 
beat  of  the  tumor." 

Mr.  Heath  thus  describes  *  the  possible  points  of  appearance  of  an 
aortic  aneurism  :  "  If  on  the  ascending  portion  of  the  arch,  the  sac 
presses  against  the  sternum,  producing  gradual  absorption  of  the  wall 
of  the  chest,  and  communicating  a  marked  impulse  to  the  right  side 
of  the  sternum  as  high  as  the  sterno-clavicular  joint,  which  may  be 
invaded  by  the  tumor  in  the  later  stages.  If  on  the  transverse  portion 
of  the  arch,  the  sac  encounters  but  little  resistance  in  an  upward 
direction,  and  hence  is  apt  to  invade  the  inter-clavicular  notch,  to 
compress  the  trachea  and  occasionally  the  oesophagus,  and  to  produce 
marked  spasm  of  the  larynx  by  interference  with  the  left  recurrent 
laryngeal.  When  a  sac  of  this  kind  rises  into  the  neck,  it  is  a  matter 
of  uncertainty  to  which  side  it  should  be  allotted,  since  a  tumor  pro- 
jecting most  to  the  right  by  no  means  necessarily  originntes  on  the 
right  side,  and  vice  versa^ 

2.  The  Pulse. — If  a  decided  diminution  is  found  in  the  right  radial 
and  carotid,  the  aneurism  is  probably  of  the  innominate ;  but  an 
aortic  aneurism  near  the  root  of  the  innominate  will  bring  about  the 
same  result. 

3.  Pressure  Symptoms. — These  will  vary  with  the  position  as  well  as 
the  size  of  each  form  of  aneurism.  Thus  in  innominate  aneurism 
pressure  symptoms  will  vary  according  as  it  is  high  up  or  low  down, 
and  pressing  inwards  or  outwards.  As  to  oedema,  the  value  of  this 
must  remain  undecided  wliile  surgeons  hold  such  opposite  views. 
Thus  Mr.  Heath  f  and  Mr.  Erichsen  ;|:  speak  of  oedema  of  the  right  side 
of  the  neck  and  upper  limb  as  first  noticed.  •  Mr.  Barwell.§  on  the 
other  hand,  speaking  more  particularly  of  the  low  form  of  innominate 
aneurism  (usually  combined  with  aortic  disease),  writes  :  "  The  point 
to  be  especially  remarked  is  this — the  pulsation,  dulness,  abnormally 
loud  heart  sound,  etc.,  are'on  and  to  the  right  of  the  middle  line ;  the 
venous  congestions  are  on  the  left  side  of  the  body,  nor  does  the  right 

participate  till  late  in  the  disease When  the  right  side  is  also 

involved,  the  aneurism  will  have  become  large." 

*  Diet,  of  Surg.,  vol.  i.  p.  81. 

f  Loc.  supra  cit. 

t  Surgery,  vol.  ii.  p.  75. 

§  Loc.  supra,  cit. 


490  OPERATIONS   ON    THE   HEAD   AND   NECK. 

I  cannot  find  that  the  other  pressure  symptoms — viz.,  laryngeal  or 
tracheal  dyspnoea,  irregularity  of  the  pupil — are  really  distinctive  be- 
tween innominate  and  aortic  aneurism. 

Mr.  Barwell  considers  that  the  following  combinations  of  sjnnptoms 
"  furnish  remarkably  positive  evidence  "  in  aortic  aneurism :  "  For 
instance,  pressure  wholly  and  entirely  on  the  right  bronchus ;  conges- 
tion of  both  arms  and  both  sides  of  the  head  and  chest ;  tumor  symp- 
toms, chiefly  about  the  second  space  and  rib,  considerably  to  the  right 
of  the  sternum;  heart  displacement,  if  any,  directly  outward;  the 
pulses  equal,  with  very  slight  sphygmographic  change — perhaps  a 
rather  sloping  up-stroke,  usually  a  blunt,  flat  apex,  absence,  jDartial  or 
total,  of  dicrotic  wave,  but  undulatory  character  of  whole  down-line 
— indicate  disease  of  ascending  aorta.  Congestion  of  the  left  arm, 
supra- clavicular  region,  and  side  of  the  head ;  aneurismal  character 
of  right  pulse  (radial  and  carotid) ;  tumor  symptoms  a  little  to  the 
right  of  the  sternum,  and  probably  some  tracheal  dyspnoea,  are  symp- 
tomatic of  aorto-innominate  aneurism.  Modification  of  left  radial 
pulse,  affection  of  left  vocal  cord,  left  venous  congestion,  tracheal 
dyspnoea,  and  obstruction  of  air  to  both  lungs,  with  tumor  symptoms 
on  and  to  the  left  of  the  median  line,  mark  disease  of  the  transverse 
aorta.  Obstruction  to  the  entrance  of  air  to  the  left  lung  alone,  Avith 
pains  at  the  back  and  along  the  intercostals,  is  indicative  of  disease 
of  the  third  part  of  the  arch." 

4.  Displacement  of  the  Heart  Doivmvards. — The  more  marked  this  is 
the  greater  is  the  probability  that  the  aneurism  is  aortic. 

Difficulties  and  Fallacies  in  the  Diagnosis. 

1.  The  proximity  of  the  heart.  "  When  there  is  a  bruit,  it  is  ex- 
tremely difficult  to  distinguish  whether  it  is  limited  to  the  tumor  or 
is  propagated  into  it  from  the  cardiac  valves ;  whether  the  pulsation  is 
limited  to  the  neck,  or  extends  also  into  the  thorax ;  and  whether  one 
only  of  the  large  vessels  is  implicated,  or  whether  others  of  the  great 
arteries  in  the  neighborhood,  or  the  whole  trunk  leading  from  the 
heart,  may  not  be  diseased  and  dilated." 

2.  "  The  growth  of  aneurisms  in  the  cellular  tissue  of  the  medias- 
tinum and  root  of  the  neck  is  so  free  that  instances  have  been  observed 
of  aneurisms  of  the  arch  of  the  aorta  causing  compression  of  the  sub- 
clavian and  carotid,  without  any  disease  of  those  vessels ;  while,  on 
the  other  hand,  if  the  aneurism  approaches  the  tubular  shape,  the 
pulse  may  be  unaff'ected  in  the  branches,  though  the  trunk  is  exten- 
sively diseased"  (Holmes*). 

8.  The  distribution  of  the  branches  of  the  aorta  may  be  anomalous.f 

*  Syd.  of  Surg.,  vol.  iii.  p.  14. 

f  Mr.  Holmes  quotes  the  following  instructive  case:  In  a  patient  in  whom,  from 
other  symptoms,  there  was  no  difficulty  in  diagnosing  an  aneurism  of  the  arch  of  the 


SUEGTCAL    INTERFERENCE    IN    THORACIC   ANEURISMS.  491 

The  following  remarks  of  Mr.  H.  Morris  on  a  case  of  aortic  aneurism 
illustrate  the  extreme  difficulty  of  diagnosing  here :  "  No  one  who  ex- 
amined this  woman  questioned  that  the  aneurism  was  innominate,  and 
some  very  capable  diagnosticians  considered  it  to  be  a  simple  sacculated 
aneurism  of  that  vessel.  Even  after  dissection  it  was  impossible  to 
make  out  its  true  character  until  the  sac  had  been  laid  freely  open  in 
front  and  the  innominate  artery  behind.  The  situation  and  outline 
of  the  tumor,  the  pain  in  the  shoulder  and  over  the  right  side  of  the 
head  and  neck,  led  to  the  diagnosis  of  innominate  aneurism.  The 
origin  of  the  disease  from  the  aorta  might  have  been  suspected  if  more 
weight  had  been  given  to  the  severe  gnmcing  pain  across  the  front  of 
the  chest  suffered  at  the  onset ;  to  the  dilated  veins  on  the  right  side  of 
the  upper  part  of  the  chest ;  to  the  equality  of  the  radial  pulses ;  to 
the  absence  of  any  cough,  dyspnoea,  and  throat  dryness,  of  any  de- 
flection of  the  trachea,  of  any  numbness  or  loss  of  power  in  the  right 
arm  (such  frequent  symptoms  in  innominate  aneurism) ;  and  to  the 
fact  that  aortic  aneurism  causes  tumors  in  the  neck." 

B.  Treatment. 

I.  Ligature.* 

Aids  in  selecting  Oases  fitted  for  Operation. — Mr.  Barwell,t 
writing  on  innominate  aneurisms,  has  formulated  the  following 
aphorisms : 

i.  An  aneurism  commencing  suddenly,  especially  if  traceable  to 
some  traumatism  or  over-exertion,  is  more  likely  to  be  benefited  by 
operation  than  one  arising  gradually  and  without  assignable  mechan- 
ical cause. 

ii.  Distinct  sacculation  is  a  most  desirable  condition  ;  fusiform  dila- 
tation of  the  innominate  Indicates  almost  certainly  a  similar  condition 
of  the  aorta  and  widespread  arterial  disease. 

iii.  If  symptoms  show  the  aortic  arch  to  be  also  affected,  the  disease 
should  be  limited — that  is,  should  not  extend  along  the  transverse 
portion.  It  should  be  of  the  sacculated  variety,  not  a  general  dilata- 
tion of  the  whole  calibre.  Absence  of  any  other  aneurism,  especially 
of  the  rest  of  the  aorta,  must  be  ascertained. 

iv.  Absence  of  rasp-sound  along  the  aorta,  or  any  other  indication 
of  extensive  atheroma,  should  be  verified. 

V.  Aortic  incompetence,  unless  very  slight,  is  a  decided  objection, 
as  is  also  mitral  disease  or  considerable  hypertrophy  of  the  heart. 

aorta,  one  circumstance  was  difficult  to  account  for,  viz.,  that  while  the  pnlse  in  the 
right  carotid  was  unaffected,  that  in  the  right  wrist  was  imperceptible.  After  death 
the  right  subclavian  was  found  to  be  the  last  branch  of  the  aorta.  Passing  between  the 
aneurism  and  the  spine  it  had  been  compressed,  while  the  carotid  was  unaffected 

*  Many  of  the  remarks  below  apply  also  to  the  two  other  methods  of  surgical  inter- 
ference— introduction  of  foreign  bodies  into  tlie  sac  and  galvano-puncture. 

f  Loc.  supra  ciL,  p.  520. 


492  OPERATIONS   ON   THE    HEAD    AND    NECK. 

vi.  The  patency  of  the  vessels  leading  to  the  brain  should  be  inves- 
tigated by  making  a  few  seconds'  pressure  on  the  carotids  alternately 
and  then  simultaneously. 

vii.  Absence  of  visceral  disease  must  be  ascertained. 

Before  deciding  to  recommend  operative  interference  in  these 
aneurisms,  the  surgeon  should,  I  think,  consider  most  carefully  the 
following  points,  which  appear  to  me  to  be  the  outcome  of  recorded 
cases : 

1.  It  is  possible  that  too  much  importance  has  been  attached  to  a 
very  few  successful  cases,  and  that  too  little  attention  has  been  given 
to  the  fact  that  numerous  unsuccessful  cases  have  occurred  which 
have  never  been  published. 

2.  It  is  certain  that,  in  some  cases,  operative  treatment  may  not 
only  fail  to  check  the  progress  of  the  aneurism,  but  may  actually  and 
decidedly  hasten  the  fatal  issue.  This  grievous  result  may  not  only 
be  brought  about  by  the  difficulties  of  the  operation  itself,  but  also  by 
this  special  and  untoward  result  which  is  common  to  all  operative 
treatment  here — viz.,  that,  as  in  these  aneurisms  the  contiguous  part 
of  the  large  vessels  (aorta  especially)  is  often  extensively  diseased, 
and  as  other  aneurisms  may  be  present,  ligature  of  one  vessel,  by 
checking  the  flow  of  blood  at  one  part,  may  throw  the  current  sud- 
denly upon  another,  perhaps  unfit  to  bear  the  strain,  or,  from  its  rela- 
tions, more  likely  to  produce  grave  pressure-symptoms.* 

"  If  the  enormous  difficulty  of  diagnosis,  the  great  risks  of  the  oi3era- 
tion,  the  possibility  of  spontaneous  imj^rovement,  if  not  of  cure,  and 
of  palliation  by  rest  and  diet,  and  also  the  fatal  results  of  recorded 
operations,  be  taken  into  due  consideration,  it  seems  that  the  distal 
ligature  on  the  right  side  should  be  limited  to  desperate  cases,  and 
then  performed  only  with  the  expectation  of  relief,  not  of  cure  " 
(Morris  f). 

Contraindications  to  Operative  Interference.— Mr.  Barwell 
(loc.  supra  cit.,  p.  528)  lays  down  the  following:  (1)  When  tumor 
symptoms  reach  widely  on  both  sides  of  the  middle  line ;  (2)  when, 
with  paralysis  of  the  left  vocal  cord,  there  is  obstruction  of  the  right 
bronchus ;  (3)  when  there  is  evidence  of  considerable  aortic  incom- 
petence; (4)  when  there  is  mitral  disease  or  considerable  cardiac 
hypertrophy  ;  (5)  when  there  is,  in  the  course  of  the  aorta,  the  rasping 
sound  of  calcification  or  advanced  atheroma,  more  particularly  if  the 

*  This  rapid  extension  of  the  aneurism  in  another  direction  after  its  original  growth 
has  been  checked  by  operative  interference  is  well  shown  by  a  case  of  Dr.  Clinrton's 
{Clin.  Soc.  Trans.,  vol.  xix.  p.  261)  in  which,  subsequently  to  galvano-puncture,  the 
blood-pressure  found  out  other  weak  spots  in  addition  to  the  original  aneurism,  thus 
bringing  about  other  saccular  projections  and  fatal  rupture  into  a  bronchus. 

f  Loc.  supra  cit.,  p.  103. 


SURGICAL   INTERFERENCE   IN  THORACIC   ANEURISMS.  493 

superficial  vessels  are  rough  and  rigid  ;  (6)  when  there  is  pain  about 
the  spine  and  intercostal  nerves  ;  (7)  when  there  is  obstruction  of  the 
left  bronchus  only ;  (8)  when  there  is  pressure  on  the  left  apex,  and 
expectoration  of  frothy  blood. 

Choice  of  Vessel. — Question  of  Simultaneous  or  Consecu- 
tive Ligature. — I  have  no  space  here  for  quoting  statistics,  which 
are,  after  all,  of  inferior  value  to  the  authoritative  opinion  of  those 
who  have  worked  most  at  this  subject.  The  earliest  and  foremost  of 
these  is  Mr.  Holmes ;  as  it  is  to  his  opinions  that  English  surgeons 
will  naturally  turn,  the  most  important  of  his  recent  views  are  given 
here. 

1.  "  One  thing,  I  think,  has  been  fully  proved — viz.,  that  the  dis- 
tinction which  was  so  much  insisted  on  between  aortic  and  innomi- 
nate aneurism  is  of  less  importance  in  regard  to  the  distal  operation 
than  used  to  be  taught,  and  that  a  case  of  innominate  aneurism  which 
otherwise  seems  appropriate  for  operation  need  not  be  rejected  be- 
cause it  is  suspected  or  known  that  the  aorta  is  also  involved.  It  has 
also  been  satisfactorily  proved  that  aneurisms  purely  aortic  have  been 
much  benefited  by  distal  operations.  It  remains  to  inquire  what 
cases  should  be  selected,  and  what  arteries  should  be  tied  in  each  case." 

2.  "  To  my  mind  the  clearest  evidence  of  benefit  has  been  in  the 
case  of  ligature  of  the  left  carotid  in  the  treatment  of  aneurism  affect- 
ing the  transverse  part  of  the  arch."  In  a  case  of  this  kind  it  was 
the  evident  extension  of  the  tumor  up  the  neck  and  towards  the 
trachea  which  made  Mr.  Holmes  think  that  the  ligature  would  prove 
beneficial,  and  the  result  even  surpassed  his  expectations,  the  patient 
being  alive  and  in  tolerable  health  five  and  probably  seven  years 
after  the  operation.  Thus  Mr.  Holmes,  considering  that  the  applica- 
bility of  the  distal  ligature  depends  largely  on  the  observed  growth 
of  the  tumor,  would  think  ligature  of  the  subclavian  justifiable  if,  in 
innominate  or  mixed  aneurism,  the  tumor  was  making  rapid  advance 
under  the  sterno-mastoid.  He  also  draws  attention  to  the  importance 
of  estimating  pressure  signs  as  indicating  extension  of  the  aneurism, 
as  evidenced  by  the  condition  of  the  veins,  the  breathing,  the  pupils, 
etc.  (p.  494). 

3.  With  regard  to  operations  on  the  right  side  in  cases  of  innomi- 
nate or  mixed  innominate  and  aortic  aneurism,  opinions  vary  as  to 
whether  the  carotid  or  subclavian  should  be  tied  simultaneously  or 
whether  the  carotid  should  be  tied  first.  Mr.  Holmes,  who  holds  this 
latter  view,  evidently  thinks  that  ligature  of  this  vessel  may  be  suffi- 
cient without  any  consecutive  ligature  of  the  subclavian,  unless  indi- 
cations arise — e.f/.,  the  manifest  growth  of  the  subclavian  portion  of 
the  sac,  or  the  effect  of  compression  of  the  subclavian  in  diminish- 
ing the  size  or  the  pulsation  of  the  tumor. 


494  OPERATIONS    ON   THE    HEAD    AND    NECK. 

Mr.  Holmes's  chief  reasons  for  preferring  ligature  of  the  carotid 
alone  as  a  first  step  are — (a)  that  while  the  number  of  cases  of  si- 
multaneous ligature  is  much  the  larger,  the  most  striking  instances  of 
success  have  followed  ligature  of  the  right  carotid  alone  ;  (b)  in  some 
cases,  where  ligature  of  the  subclavian  has  been  also  resorted  to  later, 
the  aneurism  was  already  diminishing  and  becoming  firmer  after  liga- 
ture of  the  carotid;  (c)  the  simultaneous  ligature  of  two  such  vessels 
as  the  carotid  and  the  subclavian  may  be  a  very  formidable  undertak- 
ing from  the  prolonged  dissection  and  difficulties  with  the  anaesthetic ; 
{d)  as  ligature  of  the  left  carotid  has  proved  sufficient  in  aortic  aneu- 
rism, a  similar  step  should  be  tried  on  the  right  side  in  innominate 
aneurism. 

Mr.  Barwell*  goes  a  good  deal  further,  and  thus  summarizes  the 
principal  points  which  he  believes  will  serve  to  guide  the  choice  of  the 
surgeon.     Time  alone  will  show  how  far  each  is  reliable. 

1.  Fo7~  Ligature  of  Left  Carotid. — Tumor  symptoms  upon  and  some- 
what, but  not  far,  to  the  left  of  the  middle  line,  and  rising  into  epis- 
ternal  notch,  or  beneath  left  sterno-mastoid.  Left  venus  congestion ; 
alteration  of  left  carotid,  and,  to  a  much  less  degree,  of  left  radial 
pulse.  Paralysis  of  left  vocal  cord;  obstruction  to  entrance  of  air, 
equal  on  both  sides  of  chest ;  sometimes  alteration  of  left  pujiil. 

2.  For  Ligature  of  Right  Carotid  and  Subclavian. — Tumor  symptoms 
on  right  of  middle  line.  Marked  changes  in  right  radial  and  carotid 
pulse.  Venous  congestion  on  right  side,  aff'ecting  first,  and  chiefly, 
head  and  neck.  Afterwards,  with  increase  of  tumor,  right  arm  and 
chest  and  right  vocal  cord  may  be  paralyzed. 

Tumor  symptoms  on  right  of  and  upon  middle  line,  .running  up  to 
sterno-clavicular  joint  and  episternal  notch ;  venous  congestion  on 
left  side ;  alteration  of  right  pulse  (radial  and  carotid) ;  tracheal 
dyspnoea. 

Tumor  further  to  the  right,  and  lower  (second  space) ;  congestion 
equal  on  both  sides ;  no  marked  ciiff"erence  between  the  two  pulses; 
heart  displacement,  chiefly  outwards. 

Pressure  on  right  bronchus ;  left  lung  perfectly  free ;  with  puerile 
respiration  and  perhaps  emphysema. 

With  any  of  these  conditions,  changes  of  the  right  pupil  may  be 
combined. 

3.  Doubtful  Signs  only  to  be  Read  by  the  Light  of  other  Symptoms. — 
Venous  congestion  on  the  left  side,  tracheal  dj^spnoea,  dysphagia. 

Another  interesting  and  unsettled  question  bearing  on  this  matter 
of  ligature  of  large  vessels  near  the  heart  is  the  most  appropriate 
material  for  ligature. f     While  it  is  probable  that  ligatures  of  kan- 

*  Loc.  supra  cit.,  p.  328. 

t  See  also  the  remarks  at  p.  481. 


SUEGICAL    INTERFERENCE    IN   THORACIC   ANEURISMS.  495 

garoo-tendon  and  ox-aorta  are  superior  to  silk  or  catgut,  as  the  above 
large,  strong,  slowly-absorbing  bands,  as  they  disappear,  seem  to  leave 
a  ring  of  organized  tissue  behind  them,  it  is  improbable  that  the 
greater  security  which  they  give  is  due  to  their  not  dividing  the  inner 
and  middle  coats.  Mr.  Holmes*  points  out  that  while  a  case  of  Mr. 
Barwell's  shows  that  the  ox-aorta  may  be  so  tied  as  not  to  divide  the 
inner  coat,  other  cases  show  that  this  ligature  may  produce  as  perma- 
nent and  complete  obliteration  as  any  silk  ligature ;  moreover,  a  case 
of  Mr.  Barwell's  proves  that  in  attempting  not  to  divide  the  inner 
coat,  the  surgeon  may  fail  to  close  the  vessel  at  all,  a  serious  objection 
to  the  projiosal  of  tying  arteries  without  division  of  the  iimer  coat. 

Facts  which  show  that  the  resort  to  Ligature  has  been 
justifiable. 

1.  Solidification  and  diminution  in  the  size  of  the  swelling. 

2.  Diminution  of  pulsation.  In  one  case  of  Mr.  Barwell's,t  a  month 
after  simultaneous  ligature  of  both  arteries  for  innominate  aneurism 
the  swelling  again  began  to  increase  and  the  solidifying  tumor  to 
soften,  pulsation  also  recurring ;  this  went  on  for  about  two  weeks, 
when  the  swelling  again  solidified  and  decreased,  recovery  ultimately 
taking  place. 

3.  Improvement  in  dyspnoea,  dysphonia,  and  dysphagia. 

4.  Regain  of  power  over  a  limb. 

5.  Expectoration  of  muco-purulent  discharge  which  has  been  accu- 
mulating in  the  lungs  owing  to  interference  with  exj^iration  from 
pressure  on  the  trachea. 

II.  Introduction  of  Foreign  Bodies  into  the  Sac. — This  method 
was  originally  brought  before  the  j^rofession  by  Mr.  ]\Ioore,J  who  in- 
troduced 26  yards  of  fine  wire  iron  into  an  aortic  aneurism.  No  relief 
followed,  inflammation  of  the  sac  set  in,  and  the  patient  died  five  days 
later. 

More  recently  Dr.  Cayley  has  published  a  similar  case  in  which  40 
feet  of  wire  were  introduced  by  Mr.  Hulke.  Some  relief  was  given  to 
the  i3ain,  and  some  consolidation  had  evidently  taken  place,  but  ex- 
tension followed  in  another  direction,  causing  urgent  tracheal  dyspnoea. 
On  this  account  wire  was  introduced  a  second  time,  34  feet  being  got 
in.  Death  followed  nine  days  later.  Owing  to  this  material  being 
considered  too  irritating,  it  has  not  been  much  used. 

Other  surgeons  have  made  use  of  catgut  and  horsehair,  but  with 

*  Lo7id.  Med.  Record,  18S5,  p.  53.  Mr.  Holmes  also  observes;  "Mr.  Barwell's  liga- 
ture is,  no  doubt,  flat  when  laid  on  a  table,  but  when  tied  it  is  hard  to  see  how  its  sharp 
edges  can  be  prevented  from  impinging  on  the  vessel,  and,  if  they  do,  they  will  prob- 
ably cut  the  middle  coat." 

t  Mtd.  Chir.  Trans.,  vol.  Ixviii.  p.  130. 

X  Med.  Chir.  Trans.,  vol.  xlvii.  p.  129. 


496  OPERATIONS  ON  THE  HEAD  AND  NECK. 

these  leBS  irritating  substances  the  great  difficulty  is  to  get  much  into 
the  sac,  as  they  readily  bend  on  themselves  in  the  cannula*  In  the 
summer  of  1887,  in  a  patient  of  Dr.  Pye  Smith's,  with  a  large  aortic 
aneurism  coming  through  the  chest  wall,  I  introduced  about  40  feet 
of  horsehair  by  means  of  an  ingenious  method  suggested  to  me  by  Dr. 
Perr3^  No  good  was  done,  the  patient  dying  shortly  after,  worn  out 
with  pain.  The  post-mortem  examination  showed  that  the  clot 
formed  by  the  horsehair  was  too  localized  to  have  effected  much  in 
the  huge  cavity  formed  by  the  aneurism. 

Another  method,  that  of  introducing  very  fine  needles,  is,  I  think, 
more  deserving  of  trial.  Suggested  by  Mr.  Moore,  it  has  been  tried 
by  Mr.  Heath  and  Mr.  Puzey.f  The  former  made  use  of  it  in  a  trau- 
matic aneurism  of  the  subclavian,  where  amputation  at  the  shoulder- 
joint  had  failed.  Three  pairs  of  sewing  needles  were  introduced  into 
the  tumor,  making  each  pair  cross  within  the  sac;  they  were  not  with- 
drawn until  the  fifth  day,  by  which  time  considerable  clotting  had 
taken  place.  The  aneurism  gradually  became  solid;  but  bronchitis 
supervened,  and  the  patient  sank  seventeen  days  later.  Mr.  Puzey 
followed  Mr.  Heath's  plan  in  an  aneurism  of  the  innominate,  but,  no 
apparent  effect  taking  place  at  the  end  of  four  or  five  days,  other 
needles  were  inserted  as  the  first  were  withdrawn,  but  at  different 
parts  of  the  swelling.  This  procedure  being  carried  out  for  several 
weeks,  the  aneurism  finally  almost  disappeared  behind  the  sternal 
end  of  the  clavicle.  Unfortunately,  the  needles  set  up  some  chronic 
cellulitis,  septicsemia  followed  with  vomiting,  and  fatal  rupture  of 
the  sac.  Mr.  Puzey  thinks  this  case  affords  a  warning  against  pushing 
this  treatment  too  far,  and  that  it  would  be  better  to  wait  patiently 
the  results  of  the  first  introduction  of  the  needles  before  proceeding 
to  insert  others. 

If  the  introduction  of  foreign  bodies  be  resorted  to,  antiseptic  pre- 
cautions X  should,  as  far  as  possible,  be  made  use  of.  The  following 
directions  for  the  use  of  wire  are  given  by  Mr.  Moore  :§  "  Choose  wire 
which  is  stiff  enough  to  pass  the  cannula  without  bending,  but  so  fine 
as  to  bend  easily  when  pressed  against  the  wall  within  the  aneurism. 
Provide  a  straight  short  cannula  of  thin  silver,  sharply  pointed  at  one 
end,  expanded  at  the  other,  and  let  its  tube  be  somewhat  larger  than 
is  sufficient  to  give  ready  passage  to  the  wire.     Let  there  be  also  a 

*  I  know  of  one  case  in  which  specially  prepared  very  long  pieces  of  catgut  were 
introHnced  into  an  aneurism  in  the  neck.  At  the  post-mortem  some  of  these  were 
found  to  have  passed  on,  beyond  the  aneurism,  into  the  splenic  artery. 

t  Art.  "Acupuncture,"  Did.  of  Surg.,  vol.  i.  p.  25. 

J  Mr.  Hulke  in  his  case,  in  order  to  cleanse  the  steel  wire  thoroughly,  etc.,  and  thus 
to  get  rid  of  the  risks  of  pyjemia,  soaked  it  for  twelve  hours  in  strong  liquor  potassse; 
strict  antiseptic  precautions  were  used,  including  the  passage  of  the  wire  between  car- 
bolized  sponges. 

§  Loc.  supra  cit.,  p.  135. 


SURGICAL    INTERFERENCE    IN   THORACIC    ANEURISMS.  497 

thicker  wire  which  fills  the  cannula,  and  is  flattened  at  the  end.  This 
is  for  use  as  a  probe.  Puncture  with  the  cannula  some  part  of  the 
aneurism  which  shall  not  be  opposite  to  the  presumed  situation  of  the 
aperture  from  the  artery.  Introduce  the  probe,  and  ascertain  the 
position  and  size  of  the  arterial  opening,  as  well  as  the  dimensions  of 
the  aneurism  itself.  This  would  determine  the  directions  in  which 
the  fine  wire  should  be  introduced  and  the  quantity  which  the  aneu- 
rism might  be  expected  to  hold.  Push  in  the  fine  wire,  directing  its 
point  against  the  opposite  wall  of  the  sac,  and,  whilst  introducing 
more,  divert  the  end  of  the  cannula.  The  wire  must  bend  from  its 
fixed  extremity  in  a  curve  determined  by  the  direction  given  by  the 
cannula.  Continue  to  introduce  wire  and  to  move  the  cannula,  and 
coils  of  wire  will  be  formed  of  any  required  shape  and  in  any  jDart  of 
the  sac.  In  withdrawing  the  cannula  the  wire  must  not  be  suffered 
to  remain  in  the  puncture ;  if  it  did  so,  the  issue  would  probably  be 
fatal  haemorrhage.  The  last  part  of  the  wire  must  be  pushed  ftiirly 
into  the  aneurismal  cavity  with  the  flat  end  of  thej3robe.  The  can- 
nula may  then  be  withdrawn  upon  tlie  probe,  on  the  removal  of 
which,  last  of  all,  the  skin  should  slip  back  again  over  the  tumor,  and 
the  puncture  in  the  sac  would  not  correspond  in  that  of  the  skin. 
The  puncture  might  be  covered  with  collodion," 

III.  Galvano-puncture. — This  method  has  for  its  object  the  pro- 
duction of  clotting  without  the  risks  and  difficulties  connected  with 
the  introduction  of  foreign  bodies.  Like  the  latter,  it  has  scarcely 
had  a  fair  trial,  being  too  often  not  made  use  of  till  the  size  attained 
by  the  aneurism  forbids  any  hope  of  cure,  and  almost  of  relief. 

Points  to  pay  attention  to  — (1)  To  avoid  production  of  heat, 
pain,  and  sloughing  of  the  skin,  the  current'*'  used  should  be  a  com- 
paratively weak  one.  As  an  anaesthetic  is  not  usuallj'  required,  the 
time  occupied  may  be  considerable.  (2)  The  needles  should  be  of 
steel,  as  fine  as  is  consistent  with  perforating  tlie  tissues,  in  order  to 
diminish  pain,  haemorrhage,  and  risk  of  sloughing.f  (3)  To  avoid 
the  same  risks,  the  needles  should  be  insulated  within  about  5  inch  of 
their  points  by  two  layers  of  spirit  varnish.  (4)  As  it  has  been  proved 
that  the  effect  of  electrolysis  on  blood  at  the  positive  pole  is  a  fairly 
firm  and  tenacious  dark  clot,  while  the  negative  rather  produces  a 
pinkish   frothy  substance,  it  seems  wiser  to  connect  the   needle  or 

*  Dr.  McCall  Anderson,  in  a  most  successful  case  [Lancet,  1873,  vol.  i.  p.  261),  era- 
ployed  four  to  six  cells  of  a  Stohrer's  battery.  In  a  case  of  Dr.  Ord  {Lancet,  1880,  vol. 
ii.  p.  450),  followed  by  temporary  benefit,  six  to  eighteen  cells  of  a  Foveaux's  battery 
were  used.  Dr.  Bastian  {Brit.  Med.  Journ.,  1873,  vol.  ii.  p.  595)  made  use  of  five  to. 
eleven  cells  of  the  same  battery. 

f  With  this  object,  Dr.  Bastian  used  a  small  hare-lip  pin.  Dr.  Duncan's  needles,, 
as  made  by  Weiss,  seem  very  large. 

o2 


498  OPERATIONS   ON    THE   HEAD   AND    NECK. 

needles  introduced  into  the  sac  with  the  positive  pole,  while  a  large 
sponge  wrung  out  of  warm  salt-water  is  connected  with  the  negative 
pole  and  applied  to  the  chest-wall  near  the  swelling.  (5)  A  sitting 
should  not  be  prolonged  over  thirty  or  forty  minutes.  The  punctures 
had  best  be  closed  by  collodion.  (6)  The  operation  should  not  be  re- 
peated too  soon,  time  being  allowed  for  all  local  reaction  to  cease  and 
for  consolidation  of  the  coagulum  to  occur,  which  often  takes  some 
time. 

Drawbacks  and  Dangers.— (1)  As  pointed  out  by  Mr.  Holmes, 
"  it  is  a  radical  defect  of  this  method  that  it  acts  by  inducing  '  passive  ' 
coagulation  of  blood  in  the  sac.  Hence,  it  is  inherently  uncertain, 
liable  to  cause  relapse  by  the  melting  of  the  coagulum,  or  inflamma- 
tion by  its  too  sudden  deposition.  Again,  it  is  very  liable  to  set  up 
inflammation  in  the  walls  and  contents  of  the  sac.  Then,  too,  the 
needles  sometimes  produce  eschars  at  the  points  of  their  insertion,  and 
thus  give  rise  to  consecutive  haemorrhage.  In  fact  the  cases  are  few 
in  which  a  perfectly  happy  result  has  been  obtained,  but  some  of 
these  are  worthy  of  particular  attention. 

Amongst  these  is  a  case  of  Ciniselli  (Holmes,  loc.  supra  cit.),  in  which 
an  aneurism  of  the  ascending  aorta,  quickly  increasing,  pushing  out 
the  third  and  fourth  ribs,  with  powerful  pulsation,  rapidly  diminished 
with  much  solidification  after  galvano-puncture  for  forty  minutes,  the 
patient  resuming  his  work  as  a  coachman  ten  weeks  later.  In  Dr. 
McCall's  case  the  aneurism  was  a  small  one,  about  3^  inches  in  diam- 
eter; after  galvano-puncture  on  three  occasions,  the  swelling  was  only 
about  one-quarter  of  its  previous  size,  and  for  the  most  part  very  solid. 
In  a  case  of  Dr.  Carter's  {Lancet,  1878,  vol.  ii.  p.  761),  an  aneurism  of 
the  thoracic  aorta  appearing  in  the  right  sub-clavicular  region,  and 
accompanied  by  much  pain,  was  treated  by  galvano-puncture  on  three 
occasions  with  very  great  relief,  the  pulsation  becoming  almost  imper- 
ceptible and  the  pain  disappearing. 

In  deciding  between  the  introduction  of  foreign  bodies  (e.g.,  wire) 
and  .the  use  of  galvano-puncture,  I  think  (1)  That  the  use  of  needles 
(p.  496)  deserves  a  further  trial ;  (2)  That  there  can  be  no  doubt  as  to 
the  superiority  of  galvano-puncture  over  the  use  of  wire  or  catgut. 
Even  when  some  material  is  found  less  irritating  than  wire  and  not  so 
flexible  as  catgut  or  horsehair,  and  therefore  more  manageable,  gal- 
vano-puncture will,  probably,  still  be  safer  and  more  resorted  to. 

It  is  clear,  however,  that,  if  anything  like  prolonged  relief  is  to  be 
given,  such  operations  must  be  resorted  to  at  an  earlier  date  than  has 
hitherto  been  the  case,  and  I  would  again  draw  attention  to  the 
remarks  at  p.  492  (a  point  to  which  attention  has  not  been  sufficiently 
directed),  that  surgical  interference  may,  in  cases  of  large  aneurism, 
do  more  harm  than  good  by  diverting  the  blood-current  from  the 
original  aneurism  into  some  outlying  and  unsuspected  secondary  sac. 


PART  III. 

OPEEATIONS  ON  THE  THOEAX. 


CHAPTER  I. 


REMOVAL!^  OF  THE  BREAST  (Figs.  91,  92). 

Indications. — The  following  remarks  must  be  considered  to  refer 
to  that  most  common  and  important  of  diseases — carcinoma. 

As  recurrence  after  operation  is,  sooner  or  later,  practically  certain 
in  the  great  majority  of  cases,t  a  careful  and  judicious  selection 
of  cases  is  of  the  utmost  importance.  For  such  a  purjDose  cases  of 
carcinoma  of  the  breast  fall  into  the  three  following  groups  : 

A.  Cases  to  which  an  Operation  is  altogether  unsuited,  or  especially  doubt' 
fid  and  (in  many)  dangerous. — (1)  The  very  aged,  e.g.,  after  sixt}'' ;  not 
only  are  the  aged  less  health}'^,  but  they  are  less  troubled  by  the 
cancer,  and  more  resigned.  (2)  The  unhealthily  fat  |  and  plethoric. 
(3)  Habitual  over-eaters.  (4)  Tipplers  on  the  sly.  (5)  The  subjects 
of  a  confirmed  bronchitis,  and  weak  heart.  (6)  Subjects  of  decided 
albuminuria,  cirrhosis  or  diabetes.  (7)  Extensive  disease  of  the  skin, 
accompanied  by  scattered  tubercles  or  oedema,  and,  worst  of  all,  a 
brawny,  leather-like,  greas}'  condition  of  the  skin,  with  firm  oedema 
and  open  sebaceous  glands,  approaching  the  condition  of  cancer  en 
cuirasse.    (8)  Quick  growth,  with  rapidly  increasing  fixity.    (9)  Supra- 

*  Owing  to  the  limitation  of  my  space,  I  have  been  unable  to  deal  witli  other  less 
important  operations  on  the  breast. 

f  "As  certain  as  anything  in  surgery"  (Sir  James  Paget). 

X  Sir  James  Paget,  from  whom  several  of  tlie  above  have  been  taken,  thus  writes 
{Clin.  Lects.  and  Essays,  p.  14) :  The  over-fat  are  certainly  a  bad  class,  especially  when 
their  fatness  is  not  hereditary,  but  may  be  referred  in  any  degree  to  their  over  eating, 
soaking,  indolence,  and  defective  excretions.  The  worst  of  this  class  are  such  as  have 
soft,  loose,  flabby,  and  yellow  fat,  and  I  think  you  may  know  them  by  their  bellies 
being  pendulous  and  more  prominent  than  even  their  thick  subcutaneous  fat  accounts 
for,  for  this  shape  tells  of  thick  omental  fat  and,  I  suppose,  of  defective  portal  circula- 
tion." Some  earlier  remarks  of  Sir  James  may  here  be  quoted  :  "  Such  people  must 
be  carefully  managed ;  not  fed  too  well  ;  not  kept  too  long  in  bed  ;  not  allowed  to 
retain  their  refuse  ;  and  mere  bigness  must  not  be  taken  for  plethora." 


500  OPERATIONS  ON  THE  THORAX. 

clavicular  disease.*  (10)  A  young  patient,  especially  with  a  volumi- 
nous breast,!  a  rapidly  increasing  growth,  and  a  bad  family  history. 
(11)  Of  course,  the  presence  of  carcinoma  elsewhere — e.g.^  uterus — or 
secondary  deposits. 

B.  Cases  in  ivhich  an  Operation  is  indicated. — (1)  Cases  somewhat  ad- 
vanced in  life,  for  the  younger  the  patient  the  more  active  is  the  can- 
cer. (2)  Esi^ecially  if  patients  who  are  on  in  years  are  thin  and  dry 
and  tough,  clear-voiced  and  bright-eyed,  with  good  pulses  and  diges- 
tion, and  no  cough  or  wheezing.  (3)  Small  breasts  and  little  fat.  (4) 
Where  the  growth  is  circumscribed  with  distinct  outline.  The  worst 
defined  tumors  are  the  worst  for  recurrence.  (5)  Where  the  growth  is 
very  hard.  The  "  stoniest  "  growths  are  usually  the  slowest.  (6)  Skin 
not  involved.  (7)  Absence  of  fixity.  (8)  Either  no  axillary  glands, 
or  but  very  few  involved.  (9)  Rate  of  progress  slow,  and  family  his- 
tory good. 

C.  Cases  in  which  an  Operation  is  doubtful. — These  lie  intermediate 
between  A  and  B,  both  as  to  general  and  local  points. 

Questions  which  the  Surgeon  may  be  asked,  or  which  he 
may  have  to  put  to  himself. 

1.  How  long  will  my  patient  live  if  I  do  not  operate  f  This  can  only  be 
answered  approximately  by  considering  the  average  duration  of  life 
from  the  earliest  discovery,  in  cases  of  scirrhus.  This  is  about  two 
years  and  a  half  J 

*  If  other  points  are  favorable,  and  if  it  seems  justifiable  on  account  of  pain,  threat- 
ening ulceration,  etc.,  to  give  the  patient  temporary  relief  by  the  i-emoval  of  the  breast, 
enlargement  of  glands  here  need  not  deter  the  surgeon ;  when  the  disease  has  been 
removed  below  from  the  breast  and  the  axilla,  the  supra-clavicular  glands  will,  I  believe, 
be  found  to  enlarge  slowly,  and  as  the  space  which  contains  them  is  large,  they  do  not 
become  adherent  quickly.  I  have  twice  within  the  last  four  years  operated  in  cases 
in  which  these  glands  ware  slightly  involved.  In  one  the  patient  lived  three  years, 
in  the  other  fourteen  months,  after  the  operation. 

f  The  larger  and  the  more  vascular  the  breast,  and  the  more  abundant  the  fat,  the 
more  difficult  will  it  be  to  make  certain  of  extirpating  not  only  the  growth,  but  also 
every  atom  of  the  breast. 

X  Mr.  Sibley  {Med.  diir.  Trans.,  vol.  xlii.)  gives  thirty-two  months;  Mr.  M.  Baker 
{ibid.,  vol.  xliii.)  gives  forty-three  months.  Mr.  Beck  (Did.  of  Surg.,  vol.  i.  p.  185), 
apparently  quoting  from  Prof.  Gross,  divides  the  course  of  an  ordinary  scirrhus  of  the 
breast,  unrelieved  by  treatment,  into  these  three  stages:  First,  when  the  disease  is  lim- 
ited to  the  breast,  the  duration  of  this  first  stage  averaging  fourteen  months.  Secondly, 
the  stage  of  the  skin  and  the  axillary  lymphatics,  taking  in  the  average  from  fourteen 
to  twenty  months.  Thirdly,  the  stage  of  ulceration  and  general  infection  usually 
taking  from  the  twentieth  to  the  twenty-seventh  month  to  close  the  case  in  death.  In 
atrophic  scirrhus  the  average  duration  of  cases  not  operated  on  is  given  as  eighty-two 
months,  patients  having  been  known  to  survive  fifteen  or  even  twenty  years.  With 
encephaloid  cancer  the  average  duration  is  under  a  year.  Even  after  removal  of  tiie 
breast  it  is  said  to  be  onlv  sixteen  months  and  a  half. 


REMOVAL  OF  THE  BREAST.  501 

2.  Hoic  long  inll  she  live  if  I  do  operate  f  If  the  discovery  and  the 
operation  are  early  ones,  three  years  and  a  half  may  be  hoped  for,  in 
cases  operated  on,  from  the  first  discovery  to  the  close.  Mr.  Sibley 
(Joe.  supra  cit.)  gives  fifty  three  months;  Mr.  M.  Baker  fifty-five 
months. 

3.  What  is  the  average  date  of  recurrence  after  operation  ?  About  a 
year.  Mr.  Sibly  gives  (toe.  supra  cit.)  fourteen,  Mr,  M.  Baker  thirteen, 
months.  If  anything,  the  above  averages  are  probably  too  favorable : 
wliile  the  extremes  vary  from  two  months  to  ten  years,  more  than 
half  return  within  twelve  months  ;  about  two-fifths  return  in  six 
months. 

4.  Mliat  are  the  risks  of  the  operation  itself  f  In  other  words,  what  are 
the  risks  that  the  patient,  instead  of  dying  in  one  or  two  years  of  the 
disease,  ma}'-  die  in  one  or  two  weeks  of  the  operation  ?  In  most 
cases,  with  careful  after-treatment,  the  risks  are  slight.  The  deaths 
from  operation  are  mainly  due — (a)  to  septic  causes  and  blood-poison- 
ing— e.g.,  erysipelas,  pyaemia,  etc. ;  or  (6)  to  lung-trouble — e.g.,  bron- 
cho-fmeumonia.  This  being  so,  the  mortality  formerly  given  has 
been  much  diminished  of  late  years  by  the  improvements  of  modern 
surgery.* 

Fresh  statistics,  to  be  of  any  value,  will  be  required  of  this  operation, 
performed  with  modern  completeness  and  with  strict  aseptic  precau- 
tions maintained  throughout. 

Reasons  which  may  make  a  Patient  wish  for  an  Opera- 
tion beyond  making  a  mere  Prolongation  of  Life. — These  may 
be :  (a)  Relief  from  pain,t  which  otherwise  increases  daily  ;  the  mis- 
ery of  waking  every  day  to  the  consciousness  of  an  incurable  disease  ;| 

*  Sir  Janaes  Paget  and  Mr.  Erichsen  gave  10  percent.;  Mr.  Bryant,  6  per  cent. ;  Dr. 
Stettegart,  giving  the  statistics  of  operations  performed  from  1873  to  1876  in  one  of  the 
liospitals  at  Berlin,  gives  a  mortality  of  7  per  cent,  where  the  brea'^t  alone  was  re- 
moved, and  23  per  cent,  where  the  breast  was  removed  and  tiie  axilla  cleared  out  as 
well  (Lang.  Arch.,  Bd.  xxiv.  1879).     These  statistics,  nowadays,  require  revision. 

t  The  uncertainty  of  the  pain  attendant  on  cancer  of  the  breast  is  well  known.  Al- 
most alwa3's  absent  for  the  first  year  or  more,  save  when  the  bosom  is  handled,  pain 
may  scarcely  be  present  from  first  to  last.  More  frequently  after  the  above  dates  the 
pain  becomes  increasingly  dull  and  heavy,  then  more  and  more  lancinating;  finally, 
when  the  growth  is  ulcerating,  a  hot  burning  sensation  is  substituted  for,  or  added  to, 
the  lascinating  pain  (Paget,  Surg.  Path.,  pp.  646,  647).  Thus,  while  the  growth  is 
small  and  can  be  removed  with  good  hope,  the  patient  refuses  operation  because  she 
cannot  believe  in  cancer  without  pain.  Later  on,  when  she  seeks  relief  from  her  pain, 
all  hope  of  giving  permanent  relief  has  usually  passed  away. 

X  Sir  C.  Bell's  vivid  picture  of  the  advanced  stage  of  cancer  of  the  breast  may  be 
quoted  here.  It  should  stir  up  in  every  mind  an  earnest  desire  to  secure  earlier  oper- 
ations. "  The  general  condition  of  the  patient  is  pitiable.  Suflering  much  bodily, 
and  everything  most  frightful  present  to  the  imagination,  a  continual  hectic  preys 
upon  her,  which  is  shown  in  increasing  emaciation.      The  countenance  is   pale  and 


502  OPERATIONS    ON    THE   THORAX. 

the  sometime  loathsomeness ;  the  restlessness  for  cure  (Paget),  (6) 
The  return  of  the  disease  in  the  scar  is  often  less  greivous  than  the 
original  disease — i.e.,  the  induration,  ulceration,  excavation  are  slower 
and  less  marked  than  in  the  breast-tissue.*  (c)  Death  by  deposits  in 
the  viscera,  these  being  unseen,  is  less  distressing  to  the  patient  than 
death  by  the  original  cancer  in  the  breast,  which  is  always  under  her 
eyes,  (d)  The  patient  may  have  especial  reasons  for  wishing  to  live 
and  get  about  in  comparative  comfort  for  a  year  or  so.f 

Operation  (Figs.  91,  92). — The  chief  objects  to  be  bore  in  mind 
throughout  the  operation  are — 

1.  To  get  away  every  atom  of  the  disease. — The  main  diffi- 
culties in  securing  this  are — (a)  The  fact  that  while  cancer  may  be 
actually  declared  in  the  tumor  only,  yet  the  whole  breast  is  in  a  pre- 
cancerous condition,  and  one  on  Avhich  cancer  may  easily  supervene 
if  an  atom  of  the  gland  is  left  behind.  (6)  Owing  to  the  amount  of 
fat  which  is  often  present,  it  is  very  difficult  to  make  sure  that  every 
particle  of  gland-tissue  has  been  removed,  especially  when  the  parts 
are  obscured  with  blood. 

2.  To  remove  entirely  the  lymphatic  tract  between  the 
breast  and  the  axilla. 

3.  To  clear  out  the  axilla. — This  should  be  done  as  a  regular 
thing  in  every  case  of  cancer  of  the  breast,  whether  any  glands  can  be 
felt  or  no. 

X  The  parts  having  been  well  cleansed,  including  the  axilla,  and  this 

anxious,  with  a  slight  leaden  hue ;  the  features  have  become  pinched,  the  lips  and  nos- 
trils slightly  livid  ;  the  pulse  is  frequent;  the  pains  are  severe.  In  the  hard  tumors 
the  pain  is  stinging  or  sharp  ;  in  the  exposed  surface  it  is  burning  and  sore.  Pains, 
like  those  of  rheumatism,  extend  over  the  body,  especially  to  the  back  and  lower  part 
of  the  spine;  the  hips  and  shoulders  are  subject  to  these  pains  Successively  the 
glands  of  the  axilla  and  those  above  the  clavicle  become  diseased.  Severe  pains  shoot 
down  the  arm  of  the  affected  side.  It  swells  to  an  alarming  degree  and  becomes  im- 
movable. At  length  there  is  nausea  and  weakness  of  digestion;  a  tickling  cough  dis- 
tresses her ;  severe  stitches  strike  through  the  side ;  the  pulse  becomes  rapid  and 
fluttering,  the  surface  cadaverous,  the  breathing  anxious,  and  so  she  sinks  "  {Med.  Chir. 
Trans.,  vol.  xii.  p.  223). 

*  While  this  is  correct,  local  recurrence,  as  being  constantly  visible  to,  and  dwelt  on 
by,  the  patient,  is  much  to  be  deprecated.  If  only  is  was  more  the  custom  to  operate 
very  widely  and  deeply,  and  without  attempting  much  primary  union  (p.  559),  local 
recurrence  would  be  almost  unknown. 

t  Thus,  in  a  case  mentioned  by  Sir  B.  Brodie  {Lect.  on  Path,  and  Surg.,  p.  202),  he 
declined  at  first  to  operate  on  a  lady  with  a  scirrhns  of  the  breast  on  the  point  of  ulcer- 
ating. In  a  few  weeks  the  patient  returned,  begging  to  have  the  breast  removed,  that, 
her  life  being  rendered  more  comfortable  and  active,  she  might  accompany  in  society 
an  only  daughter.  Tiie  operation  was  successfully  performed,  and  at  the  end  of  two 
years  the  patient  died  of  secondary  pleuritic  effusion. 

J  Important  points  in  the  preliminary  treatment  are  regulating  the  patient's  diet,  get- 
ting rid  of  her  refuse,  and  treating  any  bronchitis,  however  slight  this  may  appear  to  be. 


REMOVAL  OF  THE  BREAST.  503 

space  shaved,  the  patient's  neck  and  abdomen  well  protected  with 
mackintoshes,  the  arm  is  carried  away  from  the  side  and  an  elliptical 
incision  is  made  from  a  point  close  to  the  sternum,  passing  along  the 
lower  border  of  the  breast,  and  then  somewhat  upwards  towards  the 
axilla.  An  assistant  standing  opposite  to  the  surgeon  now  draws  up 
the  breast,  Avhile  the  surgeon,  taking  the  edge  of  the  cut  skin  with  his  left 
finger  and  thumb,  dissects  this  off  in  a  downward  direction  till  he  is 
well  below  the  lower  limit  of  the  breast*  Spencer  Well's  forceps 
being  applied  to  any  spouting  vessels,  an  assistant  makes  sponge- 
pressure  on  this  flap,  and  draws  the  breast  somewhat  down,  while  the 
surgeon  makes  another  elliptical  incision,  starting  from  the  same 
point  as  the  first,  but  passing  upwards  along  the  upper  limit  of  the 
breast,  and  then  descending  somewhat  to  meet  its  fellow  just  below 
the  tendon  of  insertion  of  the  pectoralis  major.  While  the  breast  is 
drawn  downwards  by  the  assistant  who  is  making  pressure  on  the 
lower  flap  to  prevent  bleeding,  the  surgeon  raises  an  upper  flap  in  the 
same  way  as  the  lower,  taking  care  to  get  above  the  upper  limit  of  the 
breast,  and  in  either  case  keeping  the  point  of  the  knife  towards  the 
skin  and  not  towards  the  breast,  but  not  sufficiently  so  to  make  "but- 
ton holes." 

Opportunity  may  be  taken  here  to  refer  to  these  elliptical  incisions, 
and  the  flaps  which  are  raised  thereby,  I  am  strongly  of  opinion 
that  the  way  in  which  they  are  often  planned  and  carried  out  is  not 
only  futile,  but  highly  perilous.  What  is  far  too  often  done,  is,  by 
means  of  such  elliptical  incisions,  to  include  the  nipple  and  a  very 
slight  margin  of  skin  on  either  side.  The  breast  is  then  quickly  re- 
moved without  any  due  precaution  as  to  getting  above  and  below  its 
limits;  the  wound  comes,  without  any  trouble,  excellently  together; 
nothing  could  look  better  at  the  time,  but  in  a  few  months  the  disease 
Inevitably  reappears.  I  believe  that  we  should  do  much  better  in 
these  days  of  antiseptic  surgery  and  skin-grafting  if  we  reverted  to  the 
ancient  method  of  deliberately  sweeping  away  the  whole  breast  and 
all  the  skin  over  it.  But  as  this  proceeding  requires  too  much  cour- 
age, especially  in  the  theatre  of  a  large  hospital,  to  allow  of  its  being 
adopted,  at  all  events  at  present,  the  surgeon  should  take  care  that  he 
does  not  fall  into  the  opposite  extreme  for  the  sake  of  turning  out  a 
.  neatly  finished  operation.  The  elliptical  incisions  should  be  carried 
very  wide  of  the  nipple,  close  to  the  lower  and  upper  limits  of  the 
breast,  and  the  flaps  should  be  reflected  well  beyond  the  breast  limits. 
No  skin  that  is  even  doubtful  should  be  hesitated  over  for  a  moment. 


*  While  the  surgeon  must  get  beyond  the  breast  so  as  to  make  sure  of  removing  all 
of  it,  he  shoud  not  carry  his  knife  farther  down  than  is  needful,  otherwise  discharges 
will  pocket  here,  and  may  travel  backwards  around  the  ribs,  pointing  at  the  angle  of 
the  seapula  (p,  507). 


604  OPERATIONS   ON   THE  THORAX. 

In  cases  of  any  standing,  all  the  skin  over  that  half  of  the  breast,  in 
which  the  cancer  is,  had  better  go.  It  may  be  answered  to  this  that 
there  will  be  a  wound  left,  gaping  more  or  less  widely.  This  objection 
can  be  met,  to  a  large  extent,  by  following  the  steps  detailed  below. 
But  if  a  gaping  wound  has,  after  all,  to  be  left,  while  it  does  not  look 
so  well  at  the  time,  it  will  give  a  far  better  result  afterwards. 

Bearing  on  the  above,  the  following  remarks  may  be  quoted,  coming 
as  they  do  from  one  who,  in  his  day,  had  a  vast  experience  of  cancer 
of  the  breast,  the  late  Mr.  C.  Moore,  of  the  Middlesex  Hospital.* 

"  Taught,  without  doubt  by  foregoing  failures,  our  surgical  ances- 
tors adopted  a  method  of  operating  which  might  well  have  been 
expected  to  prove  effectual  against  a  local  recurrence  of  the  disease. 
They  transfixed  the  base  of  the  mamma,  and,  raising  it  Avith  ligatures, 
swept  off  the  whole  organ,  together  with  all  the  skin  that  covered  it. 
The  proceeding  had  a  barbarous  appearance  enough,  but  it  was  prom- 
ising, and  if  their  knowledge  of  the  disease  had  led  the  surgeons  of 
the  time  to  adopt  it  before  the  skin  was  hopelessly  infiltrated,  they 
must  have  met  with  more  success  than  they  appear  to  have  done. 
Postponing,  however,  all  operation  until  the  skin  was  brawny  and 
filled  with  tubercles,  and  the  deeper  textures  were  involved  without 
limit,  they  failed  too  often,  with  even  such  extensive  cutting  as  they 
adopted,  to  comprehend  the  entire  disease.  It  was  a  mistaken  kind- 
ness which  led  to  a  change  of  this  mode  of  operating.  Under  the 
influence  of  a  clergyman,  who  expressed  what  must  have  been  a  pre- 
vailing horror  at  such  Amazonian  surgery,  the  practice  was  changed 
to  an  incision  in  the  integument,  which  was  reflected  in  flaps,  and 
brought  together  again  in  flaps,  after  the  removal  of  the  cancerous 
tumor. 

"  There  would  have  been  no  diminution  of  suffering  by  this  pro- 
longation of  the  operation,  and  what  was  gained  by  it  in  neatness  was 
lost  in  life.  With  the  remains  of  the  breast,  as  well  as  in  their  own 
texture,  the  flaps  enfolded  fragments  of  diseased  substance,  and  can- 
cer soon  reappeared.  It  was  an  operation  proper  to  innocent  tumors, 
Avhich  can  be  removed  without  the  needless  mutilation  of  extirpating 
the  breast,  but  was  quite  inapplicable  to  cases  of  mammary  cancer." 

The  incisions  having  been  made  as  directed,  widely  separated  from 
each  other,  the  flaps  cleared  off  till  the  limits  of  the  breast  above  and  . 
below  and  at  the  sternal  and  axillary  ends  are  clearly  definea,  all 
freely  bleeding  points  secured,  the  surgeon  proceeds  (Fig.  91),  with  his 
finger  or  the  handle  of  the  scalpel,  to  strip  the  breast  from  off  the 
cellular  layer  which  unites  it  to  the  pectoral  muscle.  Two  precautions 
should  be  taken  here  :  (1)  to  define  the  lower  border  of  the  muscle, 

*  Inadequate  Operations  on  Cancers. 


REMOVAL  OF  THE  BREAST. 


505 


otherwise  it  is  very  easy  to  strip  up  some  of  the  fibres  of  this  muscle 
also  as  well  as  the  breast  over  it ;  (2)  to  remember  that  when,  as  is 
often  the  case,  this  muscle  is  soft  and  probably  fatty,  it  is  very  easy 
to  detach  some  of  the  fibres  even  when  the  breast  is  not  adherent  to 
the  muscle.     If  it  be  found,  especially  in  a  case  of  any  duration,  that 

Ficx.  91. 


the  cancer  has  involved  any  part  of  the  muscle,  any  fasciculi  should 
be  cleanly  removed  from  their  sternal  to  their  axillary  attachments, 
cutting  across  them  at  these  points,  and  stripping  them  up  cleanly 
with  a  director ;  any  muscular  vessels  which  need  it  are  now  tied. 

The  breast  being  removed,  any  remaining  bleeding  points  should  be 
secured,  and  it  may  be  here  said,  once  for  all,  that,  in  removal  of  a 
breast,  vessels  will  be  met  with  chiefly  at  the  four  following  points: 
(1)  In  the  cut  edges  of  skin  ;  (2)  coming  through  the  pectoralis  major  ; 
(3)  at  the  outer  edge  of  the  pectoralis  major,  coming  through  the  ser- 
ratus  magnus ;  (4)  at  the  axillar}^  end  of  the  incision,  branches  from 
the  external  mammary  and  sub-scapular,  this  latter  being  usually  the 
largest  of  all. 

The  wound  left  by  the  removal  of  the  breast  being  covered  over 
with  lint  wrung  out  of  1  in  40  carbolic  solution,  the  surgeon  should  in 
every  case  of  cancerous  breast  prolong  his  incision  into  the  axilla 
along  the  lower  border  of  the  pectoral  major,  and  thence  through  the 
skin  up  to  the  biceps,  so  as  to  expose  the  cavity  freely.  A  few  light 
touches  of  the  knife  open  the  deep  fascia,  and  the  tip  of  the  finger 
then  loosens  the  glands  and  further  explores  the  cavity.  During  this 
stage  the  arm  is  drawn  more  and  more  above  the  patient's  head,  so 
as  to  open  out  the  axilla. 


506 


OPEEATIONS   ON   THE   THORAX. 


Not  only  every  gland  that  can  be  felt  or  seen  should  be  removed, 
but  also  every  atom  of  fat  that  can  be  got  out  of  the  axilla.  In  this 
substance  lie  lymphatic  glands,  which  otherwise  will  be  surely  left 
behind,  and  l)y  its  removal  a  source  of  tedious  suppuration,  which  is 
always  liable  to  follow  on  disturbance  of  fat,  will  be  avoided. 

In  removing  the  fat  and  glands  after  loosening  them  and  freeing 
them  with  the  finger,  steel  director,  or  blunt  dissector,  everything 
which  feels  like  a  pedicle,  everything  which  does  not  shell  away 
quickly,  should  be  divided,  below  a  pair  of  Spencer  Wells'  forceps, 
and  the  upper  end  tied,  or  secured,  if  preferred,  with  double  chromic- 
gut  ligatures  passed  with  an  aneurism-needle. 

Every  precaution  must  be  taken  not  to  rupture  the  axillary  vein, 
an  accident  best  avoided  by  remembering  its  position,  by  using  no 
sharp  instrument,  and  working  without  any  undue  tearing  or  force. 
The  large  subscapular  vein  nearly  always  requires  ligature,  and  if 
thiSj  or  any  other  branch,  is  torn  away  close  to  the  axillary  vein,  an 

Fig.  92. 


To  show  the  position  of  the  chief  glands  and  vessels  in  the  axilla.    (After  Sedillot.) 


accident  which  here,  as  in  branches  of  the  internal  jugular,  is  not  at 
all  unlikely  to  happen  if  undue  force  is  used,  or  if  the  parts  are  made 
adherent  by  growth,  most  embarrassing  haemorrhage  will  take  place. 
This  is  only  to  be  met  by  taking  up  the  aperture  with  a  ligature  around 
it,  if  this  be  feasible,  or  by  ligaturing  the  vein  above  and  below. 
When  the  axilla  seems  to  be  thoroughly  cleared  out,  attention  must 


REMOVAL  OF  THE  BREAST.  507 

still  be  paid  to  the  following  points :  (a)  The  edges  of  the  pectoralis 
major  and  minor,  as  glands  are  met  with  here  between  the  two  mus- 
cles (Fig.  92)  ;  (b)  the  under  surface  of  the  pectorals ;  (c)  the  apex  of 
the  axilla.  To  reach  enlarged  glands  in  either  of  these  two  latter 
situations,  both  pectorals  must  be  divided  near  their  insertions,  com- 
pletely if  necessary.  Such  a  step  Avill  cause  additional  haemorrhage, 
probably  from  the  long  thoracic  and  muscular  branches,  and  will 
call  for  thorough  drainage  and  greater  attention  still  to  keeping  the 
wound  sweet.  It  is,  however,  far  better  to  face  these  than  to  run  the 
risks,  inevitable  otherwise,  of  leaving  mischief  behind  which  the 
surgeon  will  never  again  have  so  favorable  a  chance  of  attacking,  or  of 
doing  harm  to  the  large  vessels,  by  working  in  the  dark. 

If  at  an}^  stage  of  cleaning  out  the  axilla  the  axillary  vein  is  so 
embedded  in  the  malignant  deposit  that  this  cannot  be  removed  with- 
out taking  away  a  part  of  the  vein  also,  this  may  be  done  without 
hesitation,  two  chromic-gut  ligatures  being  first  applied.* 

The  wound  is  now  thoroughly  sponged  out,  all  hajmorrhage  finally 
arrested,  and  due  drainage  provided  for.  In  doing  this  it  is  often  ad- 
visable not  only  to  pass  a  drainage-tube  from  end  to  end  of  the  wound, 
but  also  to  puncture  the  lower  flap,  if  this  is  large,  near  its  attached 
border,  and  to  bring  out  here  another  drainage-tube,  with  one  end  in 
the  axilla,  otherwise  tension,  and  burrowing  of  discharges,  which  may 
travel  round  to  the  back  along  the  ribs,  requiring  fresh  administra- 
tion of  antesthetics  and  free  openings,  are  very  likely  to  occur. 

Due  drainage  being  provided  for,  the  surgeon  sees  how  far  he  will 
be  able  to  close  the  wound.  And  without  describing  an  easy  case,  I 
would  say  at  once  that  it  is  often  possible,  by  paying  attention  to  the 
following  details,  when  the  arm  is  brought  down,  to  unite  a  wound, 
perhaps  completely,  in  which  any  attempt  to  close  the  edges  appears 
at  first  quite  hopeless.  To  begin  with,  a  very  large  number  of  sutures 
should  be  used,  upwards  of  twenty-four  perhaps  in  a  widely  gaping 
wound,  so  that  the  tension  shall  be  distributed  as  evenly  as  possible 
over  a  large  number  instead  of  falling  heavily  upon  a  few.  Secondly, 
Sir  J.  Lister's  leaden  button-suturesf  should  be  used  wherever  much 

*  In  two  cases  in  which  I  was  compelled  to  remove  a  portion  of  the  axillary  vein 
between  two  ligatures,  the  resulting  oedema  and  trouble  were  much  less  than  I  ex- 
pected; in  one  case  they  could  scarcely  be  said  to  occur  at  all. 

t  These  are  oval  discs  of  lead  from  1  inch  to  IJ  inch  long,  perforated  in  the  centre, 
and  having  the  two  sides  turned  up  in  the  form  of  projecting  wings.  They  are  applied 
as  follows:  The  free  end  of  a  stout  piece  of  wire  is  passed  through  the  hole  in  a 
button,  and  secured  by  twisting  it  round  the  wings ;  the  other  end  of  the  wire  is  then 
threaded  on  a  needle,  which  is  made  to  enter  and  emerge  an  inch  cr  more  above  and 
below  the  margin  of  the  wound;  tiie  wire  is  then  threaded  through  a  hole  in  a  second 
button,  and  when  two  or  three  such  pairs  of  buttons  are  in  place,  each  pair  is  pressed 
firmly  against  the  flaps  by  an  assistant,  while  the  surgeon  twists  the  wire  round  the 


508  OPERATIONS   ON   THE  THORAX. 

tension  is  needed.  Numerous  other  sutures  must  be  employed  as 
well,  a  dozen  or  more  of  stout  carbolized  silk  or  wire,  and  the  rest  of 
fine  silk  or  horsehair  soaked  in  carbolic  acid.  The  wires  of  the 
buttons  should  be  cut  usually  on  the  second  or  third  day  after  the 
oj^eration.  All  of  them  should  not  be  cut  at  the  same  time,  and,  with 
regard  to  these  and  other  sutures,  it  is  not  necessary  to  disturb  the 
wound  by  removing  the  sutures.  Judicious  cutting  of  those  on  which 
the  tension  is  too  great  is  all  that  is  required  at  first. 

The  wound  being  finally  cleansed,  the  drainage-tubes  syringed 
through  to  free  them  of  clots,  a  little  iodoform  is  dusted  into  the 
axilla,  strips  of  gauze,  and  then  a  piece  of  appropriate  size  and  thick- 
ness, are  laid  over  the  wound,  the  arm  and  forearm  brought  across 
the  chest,  and  a  large  gauze  dressing  thus  applied.  A  large  square 
piece  has  a  hole  cut  in  it  near  the  upper  left  or  right  corner  according 
to  the  breast  removed,  the  arm  and  forearm  being  brought  comfort- 
ably across  the  chest,  the  hand  is  passed  through  the  hole,  which  is 
next  slid  over  the  limb  till  it  is  well  up  in  the  axilla,  the  hole  being 
sufficiently  far  from  this  side  of  the  dressing  to  allow  it  to  reach  well 
into  the  scapular  region.  The  dressings  are  tlien  kept  in  situ  by 
bandaging  round  the  abdomen  and  chest,  and  over  the  clavicle  and 
point  of  the  shoulder,  the  object  being  to  distribute  the  discharges  as 
evenly  as  possible,  and  to  meet  their  tendency  to  come  through  at 
three  spots — viz.,  at  the  lower  border  of  the  dressings,  at  the  sternal 
end  of  the  drainage-tube,  and  behind  the  axilla.  It  is  well,  before 
the  arm  and  forearm  are  shut  in,  to  dust  on  a  little  zinc-and-starch 
powder  over  the  elbow  and  palm,  especially  when  the  weather  is  hot 
and  the  skin  .delicate,  owing  to  the  irritation  of  the  perspiration 
which  is  thus  shut  in. 

I  prefer  to  keep  my  patients  as  much  propped  up  as  possible,  and 
turned  on  the  sound  side,  thus  facilitating  drainage  from,  and  early 
closing  of  the  axillary  end  of  the  wound  where  cellular  tissue  has 
been  much  opened  up. 

Question  of  the  Need  of  Removal  of  the  Whole  Breast, 
and  of  Clearing  out  the  Axilla  in  Every  Case  of  Cancer. — It 
will  be  gathered  from  the  above  account  that  I  here  follow,  and  would 
advise  others  to  follow,  Mr.  Banks,  whose  views  on  this  matter  have 
been  so  clearly  and  vigorously  put  forward.* 

It  is  only  right  to  remind  my  readers  that  these  views  have  been 


wings  of  the  second  button,  so  as  to  keep  the  stitch  securely  in  position.  The  object 
of  these  sutures  is  to  relax  the  parts,  the  strain  being,  by  the  leaden  discs,  distributed 
over  a  considerable  surface,  and  the  risk  of  the  sutures  cutting  out  too  soon  diminished. 
*  Brit.  Med.  Journ.,  1882,  vol.  ii.  p.  1138;  address  before  the  Harveian  Society 
{ibid.,  1887,  vol.  i) ;  Liv.  Med.  Chir.  Journ.,  1883, 


REMOVAL  OF  THE  BREAST.  509 

latel}^  criticized  with  much  abilit}'  by  Mr.  Butlin."^  While  I  am  well 
aware  of  the  weight  that  is  due  to  his  opinion  as  that  of  a  very  high 
authority  on  malignant  disease,  the  following  are  my  reasons  for  dif- 
fering from  him  : 

Mr.  Banks  holds  most  strongly  that  in  every  case  of  cancer  of  the 
breast — (1)  The  whole  breast,  the  skin  over  it,  the  fascia  over  the  pec- 
toral muscle,  and  (if  at  all  suspicious)  the  fibres  of  this  muscle  should 
be  removed.  (2)  The  axilla  should  be  cleaned  out  whether  any  en- 
larged glands  can  be  felt  or  no. 

Mr.  Butlin  {loc.  supra  cit.,  p.  375)  considers  that  (A)  the  practice 
of  removing  the  whole  breast  is  "  theoretically  and  practically 
wrong,"  and  again  (p.  375),  he  believes  this  wholesale  method  of 
treating  cancer  of  the  breast  "to  be  unscientific  and  needlessly  cruel 
to  many  women."  Amongst  his  reasons  put  forward  with  much 
abilit}^  and  carefulness  for  preferring  a  more  partial  operation  are — 

1.  With  regard  to  recurrence.  "  Certainly,  in  the  vast  majority 
of  instances,  there  is  nothing  to  lead  one  to  believe  that  the  new 
growth  arises  in  the  outlying  lobules  of  the  mammary  gland,  or  in 
any  remains  of  the  parenchyma  of  the  gland."  If  this  view  be  cor- 
rect, it  must  be  allowed  that  extensive  operations  with  a  view  of  re- 
moving all  the  breast  are  needless,  and  deserve  Mr.  Butlin's  condem- 
nation quoted  above.  But  with  our  ignorance  as  to  how  exactly 
cancer  recurs  in  the  breast,  can  it  be  said  to  be  correct?  I  venture, 
with  all  respect,  to  hold  a  totally  different  opinion  on  this  most  car- 
dinal point.  I  hold,  with  Dr.  Creighton,t  that,  in  the  great  majority 
of  cases,  cancer  here  is  a  disease  of  a  breast  becoming  obsolete,  or 
actually  so ;  that  one  result  of  this  is  that  the  atrophying  acini  become 
so  disordered  as  to  allow  their  epithelium  to  escape  into,  and  infect, 
the  surrounding  connective  tissue.  Though  the  exact  way  in  which 
this  disbandment  of  the  epithelium  is  started  is  unknown,  it  is  a  most 
important  step,  the  connective  tissue  of  people  after  middle  life  being 
unable  to  resist  the  encroachments  of  epithelium.  |  It  is  this  which 
not  only  may  start  a  carcinoma,  but  which  makes  it  so  difficult  to 
prevent  its  recurrence,  unless  by  early  and  complete  operations,  be- 
cause the  connective  tissue  goes  widely  beyond  the  breast. 

On  this  account,  believing  that  the  whole  breast  is,  in  the  great 
majority  of  cases,  in  a  condition  to  become  carcinomatous,  and  that 
thus  partial  operations  are  liable  (especially  when  the  coarse  fat, 
which  is  often  so  abundant,  and  the  haemorrhage  in  the  operations  are 
remembered)  to  leave  behind  potential  foci  of  disease,  I  consider  that 

*  Oper.  Surg,  of  Mai  Dis.,  p.  375  et  seq. 

f  Contrib.  to  tlie  Physiol,  and  Pathol,  of  the  Breast. 

X  Other  instances  are  seen  in  the  lip  and  penis. 


510  OPERATIONS  ON  THE  THORAX. 

more  wholesale  operations  are,  in  these  days  of  modern  surgery,  the 
reverse  of  "  unscientific  and  needlessly  cruel  to  many  women." 

2.  With  regard  to  the  severity.  There  can  be  no  doubt  that  the 
more  extensive  operations  are  the  more  severe.  I  doubt,  however, 
very  strongly  whether,  at  the  present  day,  with  earlier  operations,  a 
wise  selection  and  preparation  of  cases,  with  the  antiseptic  precautions 
at  our  command,  aided  by  subsequent  skin-grafting,  the  mortality 
will  be  largely  increased.  If  there  mvist  be  an  increase,  the  gravity 
of  the  disease  for  which  the  risk  is  run,  and  the  object  that  is  in  view, 
must  not  be  forgotten. 

3.  The  mutilation.  All  will  agree  with  Mr.  Butlin  when  he 
writes,  p.  382,  "  I  believe  it  affects  women  much  more  than  we,  and 
even  they,  perhaps,  are  inclined  to  admit,  and  it  is  not  improbably 
one  amongst  several  causes  which  lead  them  to  conceal  the  presence  of 
a  tumor  of  the  breast  until  long  after  the  period  at  which  it  may  hope- 
fully be  removed."  While  this  is  a  matter  which  must  be  sorrowfully 
remembered,  and  its  explanation  weighed  with  due  reverence  when  a 
surgeon  is  inclined  to  blame  his  patient  for  having  concealed  her  dis- 
ease, I  think  that  another  and  more  potent  reason  usually  leads  women 
to  defer  the  operation  until  the  setting  in  of  the  second  stage  and  the 
commencement  of  pain,  and  that  is,  the  widespread  knowledge  of  the 
frequency  of  cancer  here,  and  the  failure  of  operations  to  exterminate 
the  disease.  If  only  we  could  show  better  results,  and,  though  not  a 
believer  in  any  extensive  curing  of  cancer,  I  believe  that  we  can  do  so  by 
combining  earlier  operation,  a  wise  selection  of  cases,  going  very  wide 
of  the  disease,  and  paying  strict  attention  to  antiseptics  throughout, 
women  would,  I  think,  come  forward  more  readily  for  treatment  with 
that  calm  good  sense  in  which,  in  addition  to  quiet  patience,  they  too 
often  surpass  us. 

(B)  That  the  axilla  should  be  cleared  out  in  every  case. — 
I  advocate  this  strongly,  for  two  reasons :  (a)  While  I  am  aware  that 
in  some  cases  of  cancer  of  the  breast  the  glands  are  never  implicated 
at  all,  while  the  disease  recurs  inveterately  in  the  scar  made  for  the 
removal  of  the  breast,  I  believe  strongly  that,  in  the  great  majority  of 
cases,  to  clear  out  the  axilla  is  the  wiser  course,  for  if  the  surgeon 
wait,  as  Mr.  Butlin  (p.  383)  advises,  till  the  glands  are  obviously  en- 
larged, or  till  there  is  fulness  not  amounting  to  actual  proof  of  en- 
largement, he  will  often  wait  till  it  is  too  late — i.e.,  till  not  only  the 
glands,  but  the  connective  tissue  and  fat  of  the  axilla,  are  implicated 
as  well,  and  till  the  supra-clavicular  glands  have  had  time  to  become 
infected,  though  not  visibly  enlarged.  (&)  I  do  not  consider,  with  the 
surger}'  of  the  present  day,  that  opening  up  the  axilla  adds  to  the 
severity  of  the  operation.  If  good  drainage  and  those  antiseptic  pre- 
cautions which  have  been  so  often  mentioned  are  duly  attended  to, 
the  axillary  wound  heals  rapidly. 


PARACENTESIS   OF  THE   CHEST.  511 


CHAPTER  II. 


PARACENTESIS  AND  INCISION  OP  THE  CHEST. 
RESECTION  OF  RIBS. 

PARACENTESIS  AND  INCISION  OF  THE  CHEST. 

Indications  for  interference  in  pleuritic  effusions.  Before  interfering 
operatively,  the  surgeon  has  two  points  to  consider.  I.  Whether 
fluid  is  present.  II.  Whether  it  is  purulent  or  not.  ^ly  space 
will  only  allow  of  my  dealing  with  the  second  of  these  points. 

II.  Is  the  fluid  purulent  or  not  ?  The  importance  of  clearing 
up  this  point  is  manifest  from  the  fact  that  if  pus  is  present  it  is  very 
rarely  absorbed ;  it  may  burst  into  the  lung,  may  burrow  about, 
making  its  way  externally,  causing  hectic,  caries,  and  lardaceous 
disease. 

A.  Exploratory  puncture  (vide  siqrra).  A  large  hypodermic  syringe 
and  needle  should  be  used,  absolutely  clean,  pervious,  and  the  needle 
sufficiently  long  and  not  too  flexible.  A  grooved  needle  should  never 
be  trusted  to.  It  is  readily  plugged  by  a  pellet  of  fat,  and  thick  pus 
will  not  flow  along  it. 

B.  Presence  of  pyrexia  and  hectic.  This  is  not  always  reliable. 
Fallacies :  (a)  They  may  be  absent,  or  little  marked,  in  empyema, 
especially  in  long-standing  cases,  the  alteration  of  the  pleura  or  the 
degree  of  tension  preventing  absorption.  (6)  Well-marked  pyrexia 
may  be  present  in  serous  effusions;  thus,  in  these,  the  evening  tem- 
perature may  reach  101°.* 

C.  The  aspect  of  the  patient.  The  tint  is  often  anaemic  and  earthy 
in  long-standing  empyema,  and  the  tinger-ends,  especially  in  children, 
clubbed. t 

D.  Age.     Empyema  is  common  in  children  X  and  young  adults. 

E.  Rigors.  These  are  often  slight,  irregular,  and  may  occur  only 
towards  evening.     In  children  they  are  often  absent  throughout. 

F.  Any  preceding  disease.  Empyema  is  not  unfrequent  after  scar- 
let fever,  measles,  childbirth,  pyaemia,  small-pox,  and  especially 
typhoid  fever.  The  onset  of  the  emp3'ema  is  most  insidious  and  often 
overlooked.    If  a  patient  during  convalescence  seems  to  go  back,  loses 

*  In  1886  I  tapped  the  chest  of  one  of  our  students,  nnder  the  care  of  Dr.  Pye  Smith, 
whose  temperature  was  103°.  The  fluid  was  serous,  and  after  the  single  aspiration  a 
good  recovery  took  place. 

t  "  If  a  child  be  seen  with  general  pallor  and  finger-clubbing,  one  ought  to  think 
of  empyema  rather  than  of  (he  other  causes  of  clubbing — viz,  chronic  bone  diseaes, 
broncliiectasis,  and  congenital  heart-disease"  (Barlow). 

X  In  children  the  pleura  seems  to  have  a  tendency  to  form  pus  (Good)iart). 


512  OPERATIONS    ON    THE   THORAX. 

his  appetite,  any  embarrassment  of  the  breathing  must  be  at  once 
looked  for,  and  empyema  suspected. 

G.  CEdema.     This  is  often  absent,  though  pus  is  present. 

H.  Other  signs,  especially  in  children,  must  be  remembered — viz., 
unexplained  and  obstinate  diarrhoea,  emaciation,  etc. 

Treatment  of  Non-purulent  Serous  Effusions.— Question 

of  operation.  If  medical  treatment — e.g.,  absorbents  and  diuretics, 
counter-irritation,  dry,  nutritious  diet,  etc. — fail,  two  questions  arise : 
A.  What  is  the  danger  of  leaving  the  fluid  ?  B.  What  is  the  risk  of 
paracentesis  ? 

A.  Danger  of  leaving  the  fluid. 

1.  There  is  the  risk  t)f  sudden  death  when  a  large,  quiet  effusion 
persists.* 

This  risk  is  greatest  in  left-sided  effusions  which  displace  the  heart 
and  cause  bending  of  the  inferior  vena  cava. 

2.  There  is  the  risk  of  the  lung  being  more  and  more  tied  down  by 
adhesions — e.g.,  when  much  lymph  has  formed. 

3.  There  is  the  risk  of  engorgement  of  the  sound  lung,  especially 
if  the  patient  is  submitted  to  a  chill. 

4.  There  is  the  risk  of  slow  pus-formation,  especially  in  a  patient 
much  let  down,  where  the  effusion  is  secondary  to  some  other  disease, 
and  where  such  a  case  gives  the  history  of  a  chill. 

B.  The  risks  of  paracentesis. 

1.  Shock.  This  is  especially  probable  in  delicate  patients  with  a 
nervous  dread  of  the  operation. 

2.  Syncope.  A  special  cause  of  this  is  perhaps  alteration  of  the  po- 
sition of  the  heart  and  large  vessels  by  removal  of  the  supporting 
fluid. 

Dr.  Moxon  showed  that  the  effect  of  the  effusion  varied  with  the 
side  affected.  Thus  an  effusion  into  the  right  chest,  not  only  pushes 
the  heart  over  to  the  left,  but  also  compresses  the  right  auricle,  and  so 
shuts  off  blood  from  the  heart,  thus  tending  to  produce  syncope  from 
cardiac  anamia.  Effusion  on  this  side  also  tends  to  make  lateral 
pressure  on  the  inferior  vena  cava,  which  is  the  more  readily  bent 
over,  as  it  has  just  passed  through  a  rigid  ring.  Effusion  into  the  left 
chest  drives  the  heart  over  to  the  right,  and,  pressing  on  the  left  auricle, 
distends  the  right  side  of  the  heart,  by  impeding  the  passage  of  the 
blood  into  the  left  ventricle,  and  thus  tends  to  bring  about  syncope 
from  cardiac  plethora.     There  is  also  a  tendency  for  the  right  lung  to 

*  I  think  it  is  Dr.  Clifford  Allbutt  wJio  records  the  case  of  a  girl  who  had  been 
brought  to  the  Addenbrooke  Hospital  with  a  large,  quiet,  serous  eli'usion.  Having  got 
out  of  the  cart  which  had  brought  her,  she  was  walking  slowly  across  the  green  in  front 
of  the  hospital,  when,  without  a  cry  or  a  stagger,  she  was  seen  to  fall  dead. 


PARACENTESIS   OF   THE   CHEST.  513 

become  oedematous  and  crepitant,  owing  to  its  being  engorged  with 
blood. 

3.  Embolism  from  detachment  of  clots  in  the  pulmonary  veins. 
That  this  is  a  real  risk  is  shown  by  a  case  of  Sir  B.  Foster's,  in  which 
clots  dislodged  from  the  right  pulmonary  veins  caused  embolism  of 
both  renal  and  iliac  arteries,  with  a  fatal  result  from  albuminuria,  sup- 
pression of  urine,  and  gangrene. 

Both  2  and  3  may  perhaps  be  prevented  by  not  drawing  off  all  the 
fluid,  and  drawing  it  ofi'  slowly. 

4.  QEdema  of  the  lung.  This  is  an  undoubted  danger.  Shortly 
after  the  tapping  (the  effusion  being  usuallj^  a  large  one),  urgent 
dyspnoea  comes  on  with  frothy,  serous  expectoration  rich  in  albumen. 
Death  usually  takes  place  in  about  twenty-four  hours.  Dr.  Duflfin's 
exj^lanation  of  this  is  probably  the  correct  one.  The  compressed  lung, 
after  the  removal  of  a  large  effusion,  corresponds  to  a  limb  after  the 
use  of  Esmarch's  bandage — i.e.,  the  vaso-motor  nerves  are  paralyzed; 
thus,  when  the  lung  expands,  sudden  stress  is  thrown  on  toneless  ves- 
sels, hence  the  transudation  of  sero-albuminous  fluid,  equivalent  to  the 
oozing  so  common  after  removal  of  the  bandage. 

Indications  for  Paracentesis  in  Non-purulent  Effusions. 

1.  Threatened  failure  of  the  heart's  action,  shown  by  the  failing 
pulse,  the  extremities  growing  cold,  etc. 

2.  In  all  cases,  and  at  any  date,  when  the  fluid  -is  so  copious  as  to 
compress  the  opposite  lung.  The  base  of  this  should  be  carefully 
watched,  and  expectoration  noted. 

3.  In  all  cases  where,  with  a  large  effusion,  there  have  been  one  or 
more  attacks  of  orthopnoea.  Relief  will  be  most  emphatically  called 
for  when,  with  this  history,  the  patient  lives  some  distance  off,  when 
he  is  no  longer  young  and  the  chest  no  longer  yielding,  or  when  the 
opposite  lung  is  at  all  oedematous. 

4.  In  all  cases  in  which  a  pleuritic  effusion,  occupying  half  one 
pleural  cavit}^,  has  existed  three  or  four  weeks,  and  shows  no  sign  of 
progressive  absorption. 

Paracentesis  for  Serous  Effusions. — Site  of  puncture.  This 
is  decided  by :  (1)  Physical  signs.  (2)  The  result  of  the  exploring 
needle.  Common  sites  are:  (a)  The  sixth  space  in  front  of  the  pos- 
terior axillary  fold,  a  spot  which  has  the  advantage  of  being  thinly 
covered,  and  where  the  ribs  are  well  apart,  (b)  In  the  seventh,  eighth, 
and  ninth  space  behind,  in  the  scapular  line.  The  eighth  space  is 
here  very  frequently  used. 

The  patient  being  turned  somewhat  over  on  to  his  sound  side,  if  he 
can  bear  this,  and  brought  to  the  edge  of  the  bed,  or,  if  he  must  be 
raised,  so  supported  that  he  can  be  readily  lowered  in  case  of  faint- 
ness,  the  surgeon,  having  seen  that  the  spot  chosen  for  puncture  is 

33 


514  OPERATIONS   ON   THE   THORA.X. 

cleansed  from  any  poultice  debris,  etc.,  and  that  his  aspirator  is  thor- 
oughly clean  and  in  good  working  order,  fixes  his  nail  just  above  the 
lower  rib,  and  holding  the  needle  so  that  it  cannot  penetrate  too 
deeply,  plunges  it  straight  into  the  pleural  cavity,  and  brings  his 
needle  into  connection  with  the  vacuum.  If  the  skin  is  very  thick, 
and  the  needle  slender,  it  is  well  just  to  make  a  puncture  with  a  scal- 
pel-point.    In  either  case  it  is  the  skin-wound  which  pains. 

The  following  practical  points  should  be  remembered:  (1)  Not 
to  catch  the  needle  on  a  rib,  a  mistake  which  is  easy  when  the  ribs  are 
close  together.  (2)  To  be  sure  and  enter  the  chest  cavity,  a  thickened 
pleura  or  false  membranes  sometimes  interfering  with  this.  (3) 
Avoiding  injury  to  the  lung,  by  not  plunging  the  needle  in  too  deeply, 
or  by  guarding  the  point  when  it  has  entered.  Usually  the  lung  is  at 
a  considerable  distance,  but  when  the  collection  is  a  localized  one, 
this  accident  may  easily  take  place.  (4)  The  fluid  should  not  be 
drawn  off  too  quickly  or  completely  ;  if  successive  vacua  are  required, 
the  later  exhaustions  should  not  be  too  complete.  The  patient  should 
always  be  warned  against  making  any  sudden  movement  or  deep  in- 
spiration. If  the  flow  stops  suddenly,  it  may  be  due  to  a  kink  in  the 
tube,  or  to  a  pellet  of  lymph  plugging  the  needle.  The  flow  should 
always  be  stopped  at  once — (a)  if  the  patient  faints,  this  being  due 
sometimes  merely  to  the  Avithdrawal  of  a  large  amount  of  fluid,  some- 
times to  the  consequent  displacement  of  viscera ;  (6)  if  any  blood  sud- 
denly appears  in  the  fluid,  this  coming  usually  from  the  rupture  of 
vascular  adhesions,  more  rarely  from  a  wound  of  the  lung  ;  (c)  if  an 
irritating  cough  is  set  up,  this  being  due  sometimes  to  the  unfolding 
of  a  temporarily  compressed  lung. 

When  the  needle  is  withdrawn,  the  puncture  should  be  at  once 
closed  with  collodion  and  iodoform. 

If  an  anaesthetic  is  asked  for,  it  may  generally  be  safely  given  with 
attention  to  the  precautions  given  below  (p.  516).  But,  as  a  rule,  the 
pain  is  so  momentary  that  this  is  not  needful.  I  have  been  disap- 
pointed with  the  results  of  injection  of  cocaine.  With  a  nervous 
patient  the  spot  may  be  marked  by  a  freezing  mixture  of  ice  and  salt, 
or  with  the  ether-spray.  A  little  stimulant  should  be  given  before  and 
after  the  operation. 

EMPYEMA. 

The  frequency  of  this  in  children  *  has  been  already  alluded  to. 

At  this  time  of  life  the  prognosis  is  good,  as  the  lungs  are  free  from 
morbid  changes.  The  formation  of  pus  may  be  very  rapid  at  this 
early  stage  of  life,  pus  being  present  by  the  fourth,  fifth,  or  seventh 

*  Out  of  forty-four  and  sixteen  consecutive  cases  of  pleuritic  effusion  at  Great  Or- 
mond  Street,  Dr.  Barlow  found  twenty-seven  and  fourteen  to  be  purulent. 


EMPYEMA.  515 

da)\  The  importance  of  this  is  considerable.  With  pvis,  lymph  is 
present  also,  and  thus — (a)  the  pleura  is  soon  altered,  thickened,  and 
less  prone  to  heal ;  (b)  the  lung  becomes  tied  down ;  (c)  the  drainage- 
tube  is  readily  blocked ;  (d)  this  lymph  leads  to  subdivision  of  the 
cavity,  and  so  to  difficulty  of  thorough  drainage  and  obliteration.  All 
this  shows  the  necessity  of  early  and  free  incision. 

Another  important  point  is,  that  pus  in  the  pleural  cavity  is  fre- 
quently localized  and  encysted  in  children.  This  is  not  uncommon 
in  the  middle  third  of  the  thorax,  the  pus  being  limited  above  by  ad- 
hesions, and  below  by  the  fixing  of  the  lower  lobe  to  the  chest  wall. 
Thus  at  this  spot  loud  bronchial  breathing  and  modified  resonance 
may  be  present.  Finally,  in  children  small  multiple  collections  are 
not  uncommon. 

The  surgeon  will  very  likely  be  asked  the  question,  whether  the  pus 
need  be  withdrawn,  if  it  will  not  be  gradually  absorbed.  The  chances 
of  this  are  extremely  small,  and  the  risks  of  leaving  it  very  great. 
They  are — (a)  external  perforation,  leading  to  the  unfavorable  results 
of  insufficient  drainage,  caries,  and  amyloid  disease.  The  most  likely 
sites  are :  In  front,  above  and  below  the  nipple ;  antero-laterally,  in 
the  fifth  space,  just  outside  the  rib  cartilages.  (6)  Lung  perforation, 
leading  to  gangrene  and  hectic,  (c)  Tuberculosis,  if  the  belief  is  cor- 
rect that  an  old  empyema,  even  if  caseated  and  inspissated,  is  still 
infective. 

Treatment  of  Empyema. 

A.  Simple  Puncture  with  Aspirator  or  Fine  Trocar.— This 

is  seldom  curative.  It  is  justifiable  in  a  few  conditions — (a)  if  the 
patient  is  very  young  or  very  timid ;  (6)  if  the  collection  is  very  small, 
or  multiple ;  (c)  if  the  patient  is  healthy,  the  pus  sweet,  and  the  re- 
filling slow ;  (d)  punctures  may  "  coax  pus  to  the  surface  "  (Good- 
hart).  Patients  thus  treated  should  be  watched  for  some  time.  In  a 
few  cases  preliminary  aspiration  is  very  useful — e.g.,  in  very  large  em- 
pyemata  of  sudden  formation.  Here  a  free  incision  may  be  followed 
by  urgent  dyspncea  from  displacement  of  viscera. 

B.  Sub-aqueous  Drainage. — This  method,  formerly  much  in 
use,  is  now  rarely  seen.  One  end  of  a  long  piece  of  india-rubber  tubing 
is  introduced,  through  a  large  cannula,  into  the  chest,  while  the  other 
end  dips  into  some  antiseptic  solution.  Advantages :  (1)  The  method 
is  simple  and  little  painful.  (2)  The  tube  is  usually  well  tolerated, 
and  (if  secured)  follows  the  movements  of  the  patient.  (3)  The 
drainage  can  be  made  gradual  and  adapted  to  the  expansion  of  the 
lung.  (4)  It  is  readily  converted  into  a  siphon  for  washing  out  the 
chest.  I  look  upon  this  last  as  of  very  doubtful  advantage,  believing 
that  if  the  pus  is  fetid  a  free  opening  should  be  made  at  once,  and  if  the 
pus  is  sweet  washing  out  is  meddlesome  and  risky.    The  disadvantages 


516  OPERATIONS  ON  THE  THORAX. 

are — (1)  The  tube,  necessarily  small,  is  easily  blocked.  (2)  Ulcera- 
tion soon  takes  place  around  the  tube,  and  thus  air  enters,  or  the  tube 
slips  out.  It  is  allowable  in  children,  or  in  very  nervous  patients, 
where  the  collection  is  not  great  or  of  long  standing,  and  the  lung  will 
therefore  be  able  to  expand  gradually. 

C.  Incision. — This  is  the  method  most  frequently  required,  espe- 
cially in  adults,  when  the  pus  is  thick  and  caseous,  when  it  is  fetid, 
and  when  it  re-accumulates  after  aspiration  quickly.  The  advantages 
are,  the  free  drainage  which  it  gives,  and  the  facilities  for  washing  out 
the  pleural  cavity  (if  this  is  required).  The  disadvantages  are,  its 
severity  and  the  tendency  to  close.  The  question  will  often  arise 
whether  a  single  or  a  double  opening  is  required.  A  single  opening  is 
usually  sufficient  in  children  and  in  young  adults,  owing  to  the 
healthy  condition  of  the  parts,  and  the  natural  tendency  to  oblit- 
eration of  the  cavity.  The  sites  usually  chosen  are  the  eighth  or 
ninth  space  in  the  scapula  line,  or  in  the  same  spaces  anterior  to  and 
below  the  scapula  angle.  I  prefer  the  latter  in  adults,  as  the  chief 
part  of  the  opening  is  anterior  to  the  latissimus  dorsi,  an  incision 
through  this  muscle,  in  adults,  having  certainly  the  risk  of  causing 
oozing  afterwards,  which  may  be  very  serious  in  a  weakly  patient. 
A  double  opening  is  occasionally  required — e.g.^  in  very  large  cavities  in 
adults,  when  the  pus  is  fetid  ;  when  the  case  is  of  very  long  standing ; 
when  the  ribs  are  very  close  together ;  when  the  pus  is  pointing  high 
up  and  anteriorly,  and  thus  the  drainage  is  inadequate. 

The  Chief  Points  of  Importance  in  Incising  an  Empyema 
are  the  following  :  Amongst  the  first  will  arise  the  question  of  giving 
an  anaesthetic.  Speaking  from  an  experience  of  thirty-one  cases,  in 
twenty-seven  of  which  an  anaesthetic  was  given,  I  believe  that  an 
anaesthetic  may  be  safely  given  in  the  vast  majority  of  cases.  On  the 
M'hole,  I  think  that  chloroform  is  the  most  suitable,  on  account  of  the 
greater  struggling  (undesirable  with  viscera  displaced),  the  dysjDnoea 
from  the  mucus  set  uj),  and  the  subsequent  bronchitis  after  ether,  but 
I  am  certain  that  the  way  in  which  the  anojsthetic  is  given  is  of  more 
importance  than  the  ansesthetic  itself. 

Of  the  twenty -seven  cases  alluded  to  above,  I  have  only  known  bad 
results  follow  the  ansesthetic  once — a  case  of  large  empyema  with  pyo- 
pneumothorax. The  heart  was  displaced  to  the  right  side,  the  face 
and  lips  somewhat  cyanotic,  the  extremities  cold,  and  the  pulse  almost 
imperceptible.  Although  the  dangers  of  an  anaesthetic  were  put  before 
him,  the  patient  insisted  on  having  one  administered.  On  the  whole, 
I  thought  ether  the  safest,  because  of  the  condition  of  the  jjulse.  It 
was  administered  carefully,  but  caused  coughing.  The  pus  was  thus 
sucked  into  a  bronchus,  up  into  the  trachea,  and  thence  drawn  down 


EMPYEMA.  517 

to  the  opposite  lung,  causing  death  rapidly.  Artificial  respiration 
expelled,  during  expiration,  pus  from  the  trachea. 

As  this  patient  was  almost  moribund  before  the  operation,  I  now 
much  regret  the  giving  of  an  anaesthetic.  It  Avould  doubtless  have 
been  wiser  to  have  refused  one,  and  trusted  to  minimizing  the  shock 
by  exhibiting  a  stimulant,  and  by  a  rapid  operation.  A  year  later  I 
Avas  asked  by  my  old  friend  Dr.  Goodhart  to  operate  on  a  somewhat 
similar  case  in  Clinical  Ward.  This  patient  was  also  young,  and  there 
was  here,  too,  a  communication  with  the  lung,  the  pus  being,  in  this 
case,  also,  fetid,  but  the  pulse  was  good  and  there  was  no  cyanosis. 
Chloroform  being  given,  the  empyema  was  incised  by  Mr.  Nicholson, 
the  clinical  assistant,  under  my  supervision.  Chloroform  in  this  case 
was  taken  well,  the  discharge  quickly  became  sweet  with  iodoform 
dressings  frequently  renewed,  and  the  patient  made  a  rapid  recovery. 

The  injection  of  cocaine  is  worth  a  trial,  but,  as  I  have  stated  above, 
it  has  disappointed  me.  While  an  anaesthetic  is  only  really  necessary 
where  two  openings  have  to  be  made,  or  where  a  rib  is  to  be  resected, 
yet  its  administration  in  capable  hands  is  usually  so  safe  that  I  always 
make  use  of  it. 

The  patient  being  supported  over  the  edge  of  the  bed  or  table,  partly 
rolled  over  on  to  the  sound  side,  or,  if  this  is  impracticable,  being 
suitably  propped  up,  the  surgeon,  having  cleansed  the  part,  fixes  a 
finger-nail  just  on  the  upper  margin  of  the  lower  rib  in  the  space 
chosen,  and  makes  an  incision  down  to  the  muscles  for  I2  to  2  inches, 
just  above  his  nail.  This  incision  having  exposed  the  muscles,  a  steel 
director  is  driven  through  into  the  chest-wall,  care  being  taken  not  to 
plunge  it  too  deeply.  A  pair  of  dressing- forceps  is  then  run  along 
the  director  and  opened  widely  both  horizontally  and  vertically. 
Owing  to  the  gush  of  pus  which  is  now  violently  expelled,  it  is  well 
to  throw  a  piece  of  lint,  out  of  carbolic  solution  (1  in  20),  over  the 
wound,  while  the  pus  is  escaping.*  The  opening  is  next  thoroughly 
dilated  by  one  or  two  aseptic  fingers,  and  the  size  of  the  cavity,  the 

*  Occasionally,  if  the  patient  struggles,  air  is  drawn  into  the  pleural  cavity  after  the 
escape  of  the  pus,  and  then  is  expelled  into  the  connective  tissue  of  the  wound,  con- 
stituting emphysema.  This  will  all  pass  off  spontaneously.  I  have  very  recently  met 
with  a  case  of  much  more  marked  emphysema  under  the  following  conditions  :  Being 
asked  by  my  colleague  Dr.  Pitt  to  incise  the  chest  of  a  child  who,  after  lobar  pneu- 
monia of  the  right  lung,  had  rapidly  developed  empyema  on  the  same  side,  I  noticed 
that,  after  the  usual  incision  at  the  angle  of  the  scapula,  the  usual  violent  outgush  of 
pus_itself  free  from  blood — was  immediately  followed  by  frothy  blood  and  a  markedly 
emphysematous  condition  of  the  wound.  I  believe  that  here  the  lung-tissue,  damaged 
by  previous  inflammation,  had  given  way  when  the  pressure  of  the  fluid  upon  it  was 
removed.  A  few  days  later  it  was  evident  that  the  lung  had  become  adherent  around 
the  incision,  which  communicated  freely  with  an  opening  in  it,  and  that  the  emphy- 
sema had  subsided.     The  case  did  well. 


518  OPERATIONS   ON    THE   THORAX. 

proximity  of  the  lung,  and  the  degree  of  granulation-formation  all 
investigated.  A  large-sized  drainage-tube  is  then  inserted,  and  care- 
fully secured  m  situ.  One  of  the  simplest,  and,  at  the  same  time,  an 
entirely  efficient  plan,  is  to  pass  two  loops  of  silk  through  the  outer 
end  of  the  tube  with  a  needle,  knot  these  loops,  and  then  place  in 
them  bundles  of  gauze  strips.  After  a  few  days  a  smaller  size,  of  the 
shape  (on  a  large  scale)  of  a  tracheotomy  tube,  may  be  worn. 

Haemorrhage  during  the  operation  is  usually  slight,  and  gives  no 
anxiety  afterwards.  If  any  point  give  trouble,  resisting  ligature,  after 
picking  up  the  tissues  with  Spencer  Wells's  forceps,  a  pair  of  these  left 
on  for  twenty-four  hours  will  probably  meet  the  case,  or  a  bit  of  a  rib 
quickly  resected  will  give  access  to  the  bleeding-point.  The  impor- 
tance of  not  cutting  through  a  thick  muscle  like  the  latissimus  dorsi 
has  already  been  alluded  to  (p.  516). 

The  opening  must  be  sufficient,  and,  if  there  is  any  doubt  about 
this,  a  part  of  a  rib  should  be  resected  without  hesitation,  especially 
where  these  are  very  close  together,  or  where  the  pus  is  foul  (vide 
infra,  p.  521). 

If  the  question  of  washing  out  the  cavity  arise,  probably  from  the 
discharge  being  foul,  it  should  be  remembered  that  this  proceeding, 
however  gently  done,  has  occasionally  brought  about  grave  and  even 
fatal  results  very  suddenly.  Whether  these  have  been  due  to  absorp- 
tion, reflex  nervous  disturbance,  or  to  dislodgment  of  thrombi,  is 
uncertain,  but  it  is  beyond  question  that  in  several  cases  symptoms 
of  impending  collapse,  and  even  death,  have  followed  on  washing  out 
an  empyema,  and  that,  too,  in  a  patient  who  is  well  on  in  convales- 
cence. Again,  it  cannot  be  too  strongly  insisted  upon  that  fretor  calls 
for  a  freer  opening,  not  for  washing  out.  If,  however,  it  is  decided  to 
make  use  of  injections,  dilute  and  bland  ones — e.g.,  Condy's  fluid — 
should  be  used,  and  these  should  be  run  in  with  a  funnel  and  tubing, 
and  not  thrown  in  with  a  syringe.  A  long  period  of  drainage  is 
often  needed  in  adults,  while  in  children  the  tube  can  be  quickly 
shortened.  In  both  sufficient  tubing  should  be  retained  to  keep 
the  opening  patent,  as  long  as  any  discharge  remains. 

During  the  prolonged  after-treatment  everything  should  be  done 
to  improve  the  general  health.  Change  of  air  is  here  a  cardinal 
point,  first,  getting  the  patient  from  his  room,  then  outside  the 
house,  and  lastly,  if  possible,  to  the  seaside.* 

*  "Last,  and  most  important  of  all — unfortunately  for  hospital  patients  a  treatment 
that  cannot  often  be  utilized — comes  Margate  air.  Any  seaside  air  is  beneficial,  but, 
weather  and  season  permitting,  I  do  not  believe  there  is  any  corner  of  England  so 
quickly  restorative  to  children  with  empyema  as  that  in  which  Margate  and  Broad- 
stairs  are  situated  ;  and,  personalh',  1  set  more  store  by  a  change  of  this  kind  after  the 
first  three  or  four  weeks  have  passed  than  in  any  continuation  of  antiseptic  dressings  " 
(Goodhart,  Dis.  of  Children,  p.  345). 


EMPYEMA.  519 

A  point  of  no  small  importance  in  the  after-treatment,  especially 
in  young  subjects  with  flexile  spines,  is  to  encourage  early,  system- 
atic, deep  breathing,  and  gymnastic  exercises,  and  thus  to  promote 
expansion  of  the  chest,  and  so  to  minimize  that  sad  sequela  of 
empyema,  irremediable  lateral  curvature. 

Before  leaving  the  subject  of  the  operative  treatment  of  empyema, 
a  few  words  should  be  said  about  the  dressing  of  these  cases.  This 
should  be  strictly  antiseptic  from  first  to  last.  The  spray  is  advisable 
in  hospital  practice,  but  not  essential  if  strict  attention  be  paid  to 
more  important  details — i.e.,  cleansing  the  parts  incised,  disinfection 
of  instruments,  taking  care  that  the  pus  escapes  under  an  antiseptic 
atmosphere,  p.  517,  a  sufficiently  free  opening,  adequate  drainage, 
abundant  dry,  aseptic  gauze  dressings,  changed  twice  perhaps  in  the 
first  twenty-four  hours,  and  then  daily  for  the  first  week.  Later  on, 
when  the  patient  is  going  away  to  the  seaside,  he  can  easily  be  in- 
structed to  remove  and  cleanse  daily  the  short  piece  of  drainage-tube 
which  keeps  the  external  opening  patent,  and  to  apply  over  the 
sinus  a  dressing  of  boracic-acid  lint  and  carbolized  tow,  with  a  pinch 
of  iodoform  dusted  on. 

Complications  of  Empyema  and  Reasons  for  Cases  not 
Doing  Well. 

1.  Persistent  septic  condition,  in  spite  of  two  openings,  free  drain- 
age, etc. 

2.  Tubercular  disease. 

3.  Lung  mischief  on  the  opposite  side — e.g.,  broncho-pneumonia, 
bronchitis. 

4.  Long  duration  of  the  case  before  it  came  under  active  treatment, 
a  free  incision  being  deferred,  or  aspiration  dallied  with. 

5.  Caries  of  the  ribs.  Multiple  spontaneous  openings,  with  burrow- 
ing sinuses  beneath  the  skin. 

6.  Age.  From  the  feebler  powers  of  repair,  and  the  more  rigid 
condition  of  the  chest  as  life  advances. 

7.  Size  of  the  empyema.  The  smaller  and  the  more  localized  the 
collection,  the  better  the  prognosis. 

8.  Collection  of  pus  forming  in  the  opposite  pleura. 

9.  Mr.  Godlee  (^Dict.  of  Surg.,  vol.  i.  p.  459)  reminds  us  that  a  curious 
complication  of  septic  cases — viz.,  cerebral  abscess — has  been  noticed 
in  a  sufficient  number  of  instances  to  make  it  impossible  to  overlook 
the  possible  association  of  one  with  the  other.  Judging  from  Dr. 
Fagge's  remarks  on  thoracic  disease  as  a  cause  of  cerebral  abscess 
(Prin.  and  Pract.  of  Med.,  vol.  i.  p.  546),  it  would  appear  that  disease 
of  the  lung  itself  is  oftener  the  primary  lesion  upon  which  the  abscess 
of  the  brain  is  dependent. 


520  OPERATIONS   ON   THE   THORAX, 


RESECTION  OF  RIBS. 

Indications. — These  are  chiefly  : 

A.  Caries  of  ribs.* 

B.  In  certain  cases  of  empyema. 

A.  In  obstinate  caries,  where  more  than  one  rib  is  affected,  where 
previous  treatment,  including  gouging,  fails,  resection  should  be  at 
once  performed.  It  is  a  very  simple  operation  in  these  cases,  as  the 
soft  tissues  are  nearl}^  healthy  and  the  periosteum  is  retained. 

An  incision,  about  2  inches  long,  being  made  over  the  centre  of 
the  carious  rib,  and  the  muscles  peeled  off  with  a  blunt  dissector,  the 
periosteum  is  next  incised,  and  separated  from  the  upper  and  under 
surface  with  an  elevator,  blunt  and  slightly  curved,  so  as  to  pass 
readily  under  the  rib  and  lever  it  upwards.  The  rib  being  thus  raised, 
it  is  easily  divided  at  one  limit  of  its  exposed  part,  either  with  a 
narrow-bladed  saw  or  with  slightly  curved  cutting  forceps.  The  soft 
parts  are  next  peeled  away  from  the  under  surface,  and  the  rib 
divided  at  the  corresponding  spot  and  removed. 

B.  In  certain  cases  of  empyema — e.g.,  (1)  when  the  drainage  is  in- 
sufficient, the  discharge  foul,  in  spite  of  one  or  two  free  openings ; 

(2)  when  the  ribs  are  too  close  together,  for  a  tube  of  sufficient  size ; 

(3)  when  an  empyema  cavity  still  persists,  though  sweet,  in  spite  of 
free  incision,  good  drainage  and  careful  dressing.  In  the  first  two 
classes  of  cases  removal  of  a  small  piece  of  one  or  two  ribs  will  be 
sufficient,  but  in  some  of  these  latter  cases  the  operation  will  necessa- 
rily be  a  much  more  severe  one.  When  called  to  a  case  of  persistent 
sinus  and  discharge  after  the  incision  of  an  empyema,  the  surgeon  on 
examination  may  find  that  the  cavity  which  remains  is  small,  and 
that  the  discharge  is  due  to  a  persistent  sinus  only.  This  should  be 
dilated  up  with  laminaria  tents,  part  of  a  rib  removed,  and  both  sinus 
and  cavity  thoroughly  scraped  out  with  sharp  spoons. 

But  in  the  majority  of  cases  of  long-standing  empyemata  the  con- 
dition of  things  is  not  so  simple  and  so  easily  dealt  with.  Oblitera- 
tion has  taken  place  often  very  imperfectly,  owing  to  the  lung  not 
being  able  to  expand,  to  the  ribs  having  fallen  in  all  they  can,  to  the 

*  In  this  most  tedious  affection,  prone  to  resist  other  treatment  and  often  provoca- 
tive of  lardaceous  disease,  resection  of  the  ribs  sliould  be  resorted  to  miicli  oftener  than 
has  hitherto  been  the  case.  Apart  from  cases  of  "strumous"  origin,  I  have  resected 
parts  of  the  fourth,  fifth  and  sixth  ribs,  keeping  up  persistent  mammary  sinuses,  and 
thought  to  be  due  to  old  abscess  of  the  breast.  In  another  patient  I  twice  resected  ribs 
in  operations  for  extirpation  of  cancer  of  the  left  breast.  Strict  antiseptic  precautions 
can  alone  justify  this,  as  the  sal  alembroth  dressings  were  placed  in  immediate  contact 
with  the  lung  and  pericardium.  Tlie  patient  is  as  yet  without  further  recurrence,  ten 
months  after  the  resection  of  tiie  ribs  and  six  years  after  the  primary  operation. 


EESECTION    OF    RIBS.  521 

diaphragm  having  risen,  and  the  opposite  lung,  heart,  etc.,  having 
come  over  as  far  as  they  are  able,  while  the  cavity,  often  large,  which 
thus  results,  is  lined  with  much  thickened  scar-like  tissue,  covered 
with  granulations  of  but  poor  vitality.  Here  portions  of  several  ribs 
must  be  removed  and  the  operation  perhaps  repeated,  in  order  that  the 
walls  of  the  cavity  may  still  further  collapse,  and  thus  obliterate  the 
cavity  while  an  opportunity  is  given  for  exploring  this  thoroughly. 

The  s^oot  chosen  for  the  resection  of  the  ribs  should  be,  as  far  as 
possible,  opposite  to  the  lung  which  can  expand  no  more,  and  the 
pieces  of  ribs  removed  should  correspond  as  closely  as  may  be  to  the 
anterior  and  posterior  limits  of  the  cavity  which  it  is  desired  to  close. 

It  has  been  thought  by  some  that  the  amount  of  rib  to  be  removed 
should  correspond  pretty  closely  to  the  distance  between  the  two 
l^leurse.  Thus  it  may  be  needful,  especially  in  an  adult,  to  remove 
pieces  of  five  or  six  ribs,  oi  inches  being  removed  from  some  and  1  to 
IJ  inch  from  others. 

Dr.  Fenger,  of  Chicago  {Med.  Neivs,  November  13,  1882),  finds  first 
the  shape  and  extent  of  the  cavity.  He  considers  that  a  cavity  which 
extends  transversely  requires  resection  of  a  large  piece  of  one  or  of  a 
few  ribs,  the  largest  piece  taken  being  that  from  the  rib  which  overlies 
the  centre  of  the  cavity.  A  vertical  cavity  covered  by  five  or  six  ribs 
will  need  resection  of  small  pieces  of  several  ribs,  from  |  to  2i  inches 
of  bone  being  removed. 

The  ribs  to  be  resected  may  be  exposed  in  one  of  two  ways.  One, 
and  I  consider  this  the  safest,  is  to  make  two  or  three  incisions,  two 
being  usually  sufficient,  and  to  raise  flaps  comparatively  small  in  size. 
The  other  is  to  raise  a  single  large  flap,  containing  in  it  any  muscles 
— e.g.,  pectoralis  major  and  serratus  magnus — which  overlie  the  ribs 
to  be  removed.  This  latter  plan  has  the  high  authority  of  Mr.  Godlee, 
who  has  done  much  to  introduce  this  operation  into  English  surgery, 
and  who  has  had  much  practical  experience  at  the  Brompton  Hospital. 
While  desirous  of  attaching  all  proper  weight  to  the  above  opinion,  I 
am  obliged  to  differ  from  it.  The  operation  is  one  of  considerable  se- 
verity, the  patient,  as  a  rule,  far  from  a  strong  one ;  thus  I  prefer  to  use 
the  operation  of  multiple  small  flaps,  rather  than  one  large  one,  on 
account  of  the  haemorrhage  being  much  less,  and,  what  there  is,  more 
easily  dealt  with. 

In  raising  his  large  flaps,  Mr.  Godlee  does  not  think  it  worth  while 
to  spend  much  time  in  trying  to  stop  the  haemorrhage,  which  is  often 
free  at  this  stage,  as  it  is  very  difficult  to  do  so,  and  as  it  will  cease 
after  removal  of  the  ribs.  While  this  last  remark  is  quite  true,  I  look 
upon  the  hemorrhage  which  must  occur  with  large  flaps  as  not  a  light 
matter  in  the  patients  with  whom  we  have  to  deal. 

I  much  prefer,  in  removing  four  or  five  ribs,  to  make  one  incision 


522  OPERATIONS   ON   THE  THORAX. 

between  two,  deal  with  these,  and  then  to  make  another  over  the 
centre  of  the  three  which  remain.  Small  incisions  being  made  at  right 
angles  to  the  long  ones,  flaps  of  skin  and  fascia,  parallelogram  in  shape, 
are  raised,  the  muscles  are  then  peeled  off  each  rib  with  a  blunt  dis- 
sector or  slightly  curved  elevator.  Care  must  now  be  taken  to  leave 
the  periosteum  on  the  rib,  and  by  no  means  to  strip  it  off.  If  it  be  left 
behind  with  the  muscles,  it  will  throw  out  callous  material,  which  will 
be  as  unyielding  as  the  bones  removed.  The  elevator  is  then  slipped 
under  the  rib,  run  along  close  to  its  posterior  aspect,  to  one  limit  of  its 
bared  surface,  and  the  rib  divided  here  either  with  a  narrow  strong- 
backed  saw — an  osteotomy  saw  or  a  Fergusson's  jaw-saw  answers  the 
purpose  excellently — or  with  cutting  forceps.  The  rib  being  then 
raised  up  when  cut  is  divided  again  at  a  corresponding  spot,  and  as 
many  as  it  is  desired  treated  in  the  same  way.  Each  piece  of  rib 
should  show  clean-cut  surfaces  at  either  end,  and  be  covered  with 
periosteum. 

Mr.  Godlee  advises  removing  as  much  as  possible  of  the  thickened 
pleura,  which  is  now  exposed,  and,  with  it,  any  periosteum  which  has 
been  left  behind.  Some  square  inches  of  this  may  be  taken  away 
without  fear  of  serious  hsemorrhage,  if  it  is  snipped  through  gradually 
with  curved  blunt-pointed  scissors,  the  vessels  met  with  being  easily 
secured. 

The  cavity  may  now  be  thoroughly  explored  with  the  finger  or  a 
soft  catheter.  If  very  foetid  it  may  be  mopped  out,  gently,  with  a 
solution  of  zinc  chloride  (gr.  xx-|j),  though  it  is  best  to  dispense 
with  this,  if  possible,  from  fear  of  coming  in  contact  with  important 
parts,  such  as  the  pericardium,  root  of  the  lung,  etc.  It  is  preferable, 
in  cases  of  foetor,  to  blow  in  iodoform  mixed  with  finely  powdered 
boracic  acid.  Drainage-tubes  are  then  inserted,  if  needful,  and  if  a 
large  flap  has  been  raised,  this  is  secured  in  situ  with  a  few  points  of 
suture.  If,  on  the  other  hand,  as  recommended  here,  multiple  small 
flaps  have  been  raised,  no  sutures  should  be  inserted,  as  primary  union 
cannot  take  place,  and  discharges  might  be  pent  up. 

The  wound,  at  the  bottom  of  which  probably  lies  the  lung  covered 
over  only  with  visceral  pleura,  is  lightly  filled  with  strips  of  aseptic 
gauze  and  boracic-acid  lint,  and  salicylic  wool  or  carbolized  tow  re- 
tained with  a  many-tailed  bandage.  If  strict  precautions  are  taken 
by  cleansing  the  instruments,  covering  over  the  wound  with  carbolized 
lint  whenever  practicable,  the  spray  need  not  be  used,  and  a  source  of 
chill  and  shock  thus  avoided. 

With  regard  to  the  date  at  which  ribs  should  be  partially  resected 
in  long-standing  cases  of  empyema,  most  surgeons  who  have  seen 
much  of  these  troublesome  cases  will,  I  think,  agree  that  the  operation 
should  be  performed  as  soon  as  the  natural  powers  of  obliteration  are 


DEAINAGE   OF   LUNG-CAVITIES.  523 

at  a  standstill,  care  being  taken  that  the  patient  has  recovered  from  the 
effects  of  the  first  operation  and  perhaps  recruited  his  strength  in  the 
meantime  at  the  seaside. 

Estlander,  who  first  introduced  this  operation,  advises,  on  the  other 
hand,  that  the  operation  should  not  be  made  use  of  too  early,  as  he 
considers  it  essential  that  the  two  layers  of  pleura  should  be  changed 
into  thick,  firm  connective  tissue,  for  the  operation  to  succeed.  Thus 
an  interval  of  six  or  eight  months  after  the  formation  of  the  empyema 
would  seem,  according  to  this  view,  to  be  the  proper  time  for  resection 
of  ribs ;  but,  on  the  other  hand,  too  unyielding  a  condition  of  the  chest 
walls,  too  thick  a  layer  of  scarred  pleura  and  pyogenic  membrane  are 
conditions  not  to  be  waited  for. 


CHAPTER   III. 

DRAINAGE  OF  LUNG-CAVITIES. 

Indications. — Operative  interference  is  justifiable  where  there  is  a 
lung-cavity  due  to  bronchiectasis,  gangrene,*  or  hydatid,  and  most  of 
the  following  conditions  are  present. 

When  previous  treatment  has  failed,  when  it  is  evident  that  the 
cavity  is  insufficiently  drained  through  a  bronchus,t  and  the  conse- 
quent abundant  muco-purulent,  foetid  expectoration  exhausts  the  pa- 
tient, with  harassing  cough,  irritative  diarrhoea,  and  commencing 
hectic.  When  the  cavity  is  limited  and  can  be  accurately  localized,! 
when  the  surrounding  lung-tissue  is  not  yet  infected,  and  the  opposite 
lung  is  healthy.  When  the  cavity  is  sufficiently  near  the  surface  to 
be  got  at,  and  when  it  is  in  a  region  that  can  be  safely  attacked.§ 
When  that  part  of  the  pleural  sac  which  overlies  the  lung-cavity  is 
obliterated.]  I 

*  Mr.Godlee  [Lancet,  1887,  vol.  i.  p.  459)  is  of  opinion  that  most  gangrenous  abscesses 
are  the  result  of  acute  pneumonia,  and  situated  near  the  bases.  The  occasional  exist- 
ence of  a  foreign  body  as  a  cause  of  the  trouble — viz.,  a  piece  of  bone  or  a  blade  of 
grass,  etc. — should  not  be  forgotten. 

t  If  the  surgeon  wait  too  long  in  dealing  with  a  gangrenous  abscess,  foetid  fluid 
from  this  may,  by  getting  into  the  bronchi,  reach  the  other  lung  and  set  up  most 
serious  damage  there. 

X  In  other  words,  when  the  whole  bronchial  tree  is  not  dilated  in  one  and  perhaps 
both  lungs  (Dr.  "Williams,  Med.  Chir.  Trans.,  vol.  Ixix.  p.  317). 

^  Drs.  Fenger  and  Hollister,  of  Chicago  (Amer.  Journ.  Med.  Sci.,  1882,  vol.  ii.  p.  370, 
a  paper  which  will  well  repay  reference),  point  out  that  a  cavity  covered  by  the  scap- 
ula, or  in  the  supra-scapular  region,  must  be  at  present  considered  inaccessible.  Access 
can  be  best  got  from  the  mammary  and  axillary  regions. 

!|  This  point  is  of  the  greatest  importance,  chiefly  from  the  probably  foul  nature  of 
the  cavity  contents,  and  the  risk  of  setting  up  a  foetid  pyo- pneumothorax  when  the 


524  OPERATIONS  ON  THE  THORAX. 

The  two  American  writers  just  quoted  show  that  adhesions  may 
be  expected  when  the  abscess  cavity  is  large,  or  where  several  attacks 
of  disease  have  occurred  in  that  part  of  the  lung  in  which  the  cavity 
now  exists.  If  the  surgeon  is  in  doubt  as  to  the  condition  of  the 
pleura  here,  he  should  make  an  incision  down  to  the  intercostal 
muscles,  pass  a  needle  into  the  lung,  and  watch  it  during  respiration. 
If  it  does  not  move  synchronously  with  this,  there  are  certainly  ad- 
hesions, and  the  lung  may  be  cut  into  without  fear. 

The  coexistence  of  empyema,  of  pleurisy,  of  a  tendency  to  general 
bronchitis,  will  be  examined  into,  and  the  amount  of  each  and  the 
importance  in  prognosis  duly  weighed.  Finally,  come  more  general 
points — e.g.,  the  age  of  the  patient  and  the  history  must  be  con- 
sidered. 

In  endeavoring  to  estimate  the  size  of  the  cavity  before  exploring 
it,  the  following  possible  fallacies  will  be  remembered : 

Dr.  Williams  {loc.  supra  cit.)  points  out  (1)  that  the  empyema  which 
invariably  accompanies  the  globular  form  of  bronchial  dilatation, 
often  entirely  masks  the  physical  signs  of  a  cavity,  even  when  the 
patient's  sensations  and  the  amount  and  character  of  the  expectoration 
point  to  the  presence  of  a  bronchiectasis ;  (2)  that  the  character  of 
the  cavernous  sound  heard  over  bronchial  dilatation  is  so  jarring  in 
tone  that  it  is  audible  over  a  far  larger  area  of  chest-wall  than  that 
immediately  overlying  the  cavity.  On  this  account  the  size  of  the 
bronchiectasis  is  often  thought  to  be  larger  than  it  eventually  proves 
to  be.  This  jarring  note  is  more  common  in  bronchiectasis  associated 
with  interstitial  pneumonia  and  fibrosis,  than  in  the  globular  bronchi- 
ectasis accompanied  with  chronic  bronchitis  and  empyema, 

Mr.  Godlee,  in  his  lectures,  to  which  I  have  already  referred,  shows 
that  the  amount  of  expectoration  is  no  criterion  as  to  the  size  of  the 
cavity,  as  each  pellet  irritates  the  bronchi  in  its  way  over  them,  and 
causes  a  great  secretion  of  mucus.* 

Operation. — The  ansesthetic  should  be  given  slowly  to  avoid 
coughing,  and  the  patient  kept  on  his  back  as  much  as  possible,  these 
two  precautions  being  intended  to  prevent  fluid,  coughed  out  of  the 
cavity,  dangerously  obstructing  the  bronchi. 

If  the  exact  position  of  the  cavity  is  doubtful,  a  preliminary  aspira- 
tion or  exploring  trocar-puncture  f  should  be  made  use  of. 

lung-cavity  is  opened,  and  even  graver  and  much  more  urgent  danger  from  cutting 
into  a  healthy  pleural  cavity. 

*  Thus,  he  has  cured  by  incision  a  cavity  which,  really  holding  only  an  ounce, 
caused  expectoration  of  more  than  a  pint. 

t  With  reference  to  this  step,  Mr.  Godlee's  remark  should  be  remembered.  "  It  is 
impossible  to  penetrate  the  lung  with  any  amount  of  accuracy  or  definiteness,  because 
it  recedes  before  even  the  sharp  point  of  a  needle." 


DRAINAGE   OF   LUNG-CAVITIES.  525 

An  incision  H  inches  long*  is  then  made,  taking  the  needle  or 
trocar,  if  used,  as  a  guide,  in  the  middle  of  an  intercostal  space  down 
to  the  muscles,  which  are  next  torn  through.  The  lung-tissue  with 
the  overlying  pleura  f  is,  perhaps,  best  opened  with  a  medium-sized 
trocar  and  cannula,  and  the  opening  then  dilated  with  dressing- 
forceps.  The  finger  is  then  gently  inserted  to  ascertain  Avhether  any 
dead  cast-off  lung-tissue  J  is  present,  and  to  find  out  the  lowest  point 
at  which  to  make  a  counter-opening.§ 

A  full-sized  drainage-tube  should  be  inserted,  soft,  for  fear  of 
haemorrhage  from  friction  and  ulceration,  and  sufficient  aseptic  dress- 
ings, iodoform  or  sal  alembroth  gauze  with  salicylic  wool  applied. 

As  a  cavity  which  gives  unequivocal  evidence  of  its  existence  may 
be  missed  [j  by  making  one  puncture  and  then  incising  at  that  sjoot, 
and  as  the  exploring  finger  or  director  may  push  the  cavity  to  one 
side,  the  lung  should  be  explored  at  several  spots  if  needful.  If  the 
pleura  is  not  adherent  over  the  cavity,  it  will  be  but  little  good 
stitching  the  lung  so  as  to  obliterate  the  pleural  sac  here,  as  stitches 
so  used  are  very  difficult  of  insertion  and  soon  cut  out  (Godiee).  If 
any  foul  fluid  escape  into  the  pleural  cavity,  this  must  be  treated 
like  an  empyema  (p.  516). 

Hsemorrhage  is  not  commonly  met  with  after  puncturing  the  lung, 
as  this  is  probably  solidified  and  altered  round  the  abscess  cavity.    If 

*  It  is  wise  to  make  a  sufficiently  free  incision  to  prevent  the  risk  of  subciitaneous 
emphysema.     In  one  case  foetid  emphysema  took  place  and  disappeared. 

f  In  addition  to  the  aids  already  given  for  deciding  as  to  whether  the  pleura  is 
adherent  or  not,  the  state  of  the  intercostal  spaces  may  help,  i.e.,  whether  they  are 
depressed  on  deep  breathing. 

X  Rokitansky  (Path.  Anat.:  Syd.  Soc.  Trans.,  vol.  iv.  p.  96)  speaks  of  having  met 
with  a  walnut-sized  piece  of  dead  lung  in  circumscribed  gangrene  of  that  viscus. 
Wagner  (Berl.  Klin.  Woch.,  September  6,  1880)  removed  a  piece  of  gangrenous  lung- 
tissue  by  an  opening  made  for  evacuating  an  empyema,  the  patient  recovering.  In 
some  cases  broken-down  lung-tissue  may  be  all  that  is  met  with;  very  little  fluid, 
if  any,  being  present. 

§  It  is  wiser  to  make  two  openings,  one  at  the  most  superficial  part;  then  from 
this  to  explore  the  cavity  and  to  try  and  find  the  lowest  part  for  making  a  counter- 
opening,  and  thus  to  secure  complete  evacuation.  Simple  drainage  with  a  single 
opening  is  often  not  sufficient,  washing  out  being  usually  required  to  arrest  the  foetor. 
If  this  washing  out  be  done  from  a  single  opening,  the  fluid,  having  no  escape,  irritates 
the  bronchi  and  sets  up  much  cough.  The  counter-opening  is  best  made  on  some 
unyielding  body,  such  as  a  sound.  Occasionally  the  cavity  comes  to  the  surface  at 
several  points. 

II  It  is  possible  that,  after  such  a  fruitless  exploration  and  the  insertion  of  a 
drainage-tube,  pus  may  burst  into  it,  as  happened  in  Dr.  Cayley  and  Mr.  Gould's 
case  {3Ied.  Chir.  Trans.,  vol.  Ixvii.  p.  209),  but  this  did  not  happen  in  a  case  of  Mr. 
Godlee's,  though  the  patient  recovered.  While  the  puncture  may  yield  no  fluid,  gas 
may  escape,  showing  that  gangrenous  lung  has  been  reached. 


526  OPERATIONS   ON   THE   THORAX. 

it  be  severe,  the  cavity  must  be  plugged  with  aseptic  gauze.  When 
any  rotten  lung-tissue  has  been  removed  with  the  finger,  hajmorrhage 
is  to  be  expected. 

If  the  cavity  be  due  to  a  hydatid,  the  cyst-wall  may  perhaps  be 
expelled  when  coughing  is  set  up  by  the  incision  of  the  cavity.  If  it 
does  not  so  come  away,  it  should  be  removed,  if  this  can  be  effected, 
without  setting  up  haemorrhage.  A  good  instance  of  how  large  cavi- 
ties in  the  lung  may  be,  when  due  to  this  cause,  is  given  by  a  case  of 
Dr.  Fenger's  (Lond.  Med.  Rec,  1881,  p.  327),  in  which  he  successfully 
operated  by  an  incision  in  the  third  space  (through  adherent  pleura), 
on  a  large  gangrenous  cavity  in  the  right  lung,  reaching  from  the 
second  to  the  fifth  rib,  and  from  the  sternum  to  the  posterior  axillary 
line. 

After-treatment. — The  cavity  should  be  syringed  out  with  a  1  in 
50  solution  of  carbolic  acid,  till  foetor  disappears,  and  then  with 
thymol  lotion.  The  drainage-tube  must  be  retained  until  the  cavity 
has  almost  completely  closed — i.e.,  until  the  discharge  has  almost,  and 
the  expectoration  has  quite,  stopped.  If  the  tube  be  removed  too 
early,  refilling  up  of  the  cavity,  with  return  of  fever,  nausea,  expec- 
toration, etc.,  are  certain.  Moreover,  as  the  external  opening  tends  to 
close  before  the  cavity  is  obliterated,  any  foul  remaining  matter  which 
does  not  escape  will  be  drawn  into  the  bronchi  and  set  up  diffuse 
bronchitis  and  broncho-pneumonia. 

The  general  health  must  be  sustained,  and  every  attempt  made  to 
secure  fresh  air,  whether  in  the  patient's  room,  or  by  getting  him  as 
soon  as  possible  into  another  room,  and  out-of-doors. 

Even  if  the  operation  does  not  save  life,  it  may  make  the  remainder 
much  more  comfortable  both  to  the  patient  and  his  friends. 

Dangers  and  Difficulties  in  Opening  a  Lung-Cavity. 

1.  Dyspnffia,  coughing  and  choking  expectoration  with  the  anaes- 
thetic, p.  524. 

2.  Pleural  adhesions  absent,  p.  524,  or  so  soft  that  they  easily  break 
down  the  lung,  thus  being  pushed  away  from  the  ribs  (Godlee). 

3.  Missing  the  cavity  and  damaging  healthy  lung-tissue.  This  is 
best  avoided  by  careful  preliminary  use  of  an  aseptic  fine  trocar  or 
large  morphia-needle. 

4.  Getting,  as  a  result  of  the  operation,  diffuse  broncho-pneumonia, 
pleurisy,  pleuro-pneumonia,  in  the  lung  operated  on  or  its  fellow. 

5.  Severe  haemorrhage,  causing  much  trouble,  owing  to  the  haemop- 
tysis, with  the  anaesthetic  (Godlee),  and  later  on  setting  up  septic 
inflammation  of  the  lung. 

6.  Finding  a  large  branching  cavity,  with  numerous  caverns, 
difficult  or  impossible  to  drain. 

7.  If  the  bronchi  are  dilated  and  contain  fluid  similar  to  a  cavity, 


DRAINAGE   OF   LUNG-CAVITIES.  527 

this  may  be  drawn  from  a  bronchus  by  preliminary  puncture.     This 
is  then  mistaken  for  a  cavity,  and  cut  down  upon. 

8.  A  cavity  near  the  root  of  the  large  vessels. 

9.  Much  consolidation  of  the  lung-tissue  over  the  cavity. 

10.  As  a  result  of  the  operative  interference,  secondary  rapid 
sloughing  and  gangrene  of  the  lung  may  follow. 

This  seems  to  have  happened  in  an  interesting  case  reported  by 
Dr.  J.  Smith,  of  Halifax  {Lancet,  1880,  vol.  ii.  p.  86).  Decided  relief 
and  improvement  followed  on  the  opening  of  what  was  apparently  a 
large  cavity,  but  death  took  place  in  about  a  fortnight.* 

*  The  conclusions  with  which  Mr.  Godlee  {Lancet,  1887,  vol.  i.  p.  718)  sums  up  his 
most  valuable  lectures  on  this  obscure  and  difficult  subject  may  be  quoted  here:  "1. 
Gangrenous  cavities  should  always  be  sought,  and,  if  possible,  opened;  and  the  prog- 
nosis, if  the  operation  be  successful,  is  not  bad.  2.  The  same  may  be  said  in  regard  to 
abscesses  caused  by  the  rupture  of  purulent  collections  from  other  parts  into  the  lung, 
at  least  as  regards  the  pulmonary  complication.  8.  Abscesses  connected  with  foreign 
bodies  must  be  opened,  and,  if  the  body  be  not  found,  it  must  be  remembered  that,  if 
of  any  considerable  size,  it  probably  lies  pretty  near  the  middle  line.  If  possible,  these 
cases  should  be  treated  early  by  ti-acheotomy  and  incision.  4.  Bronchiectatic  cavities, 
when  single  (a  very  rare  condition),  will  be  cured  by  operation.  When  multiple 
(a  very  common  condition),  they  offer  but  small  chance  of  relief  by  our  present  surgi- 
cal methods.  Still,  for  the  reasons  stated,  an  attempt  may  be  made  to  open  the  main 
one,  if  such  is  to  be  found,  but  only  if  the  pleura  has  been  ascertained  to  be  adherent. 
5.  Tubercular  cavities  should  only  be  opened  in  cases  where  the  cough  is  harassing 
and  the  cavity  single.  Injections  may  be  used  to  relieve  symptoms,  but  cannot  be 
expected  to  be  curative." 


PART  IV. 

THE    ABDOMEN 


CHAPTER  I. 

LIGATURE  OF  VESSELS. 

EXTERNAL  ILIAC.   COMMON  ILIAC.    INTERNAL  ILIAC. 
ABDOMINAL  AORTA.    GLUTEAL.    SCIATIC. 

LIGATURE   OF  THE  EXTERNAL  ILIAC  (Fig.  93). 

Indications. — Chiefly : 

1.  Some  cases  of  aneurism  of  the  upper  part  of  the  femoral,  or  of 
the  femoral  encroaching  on  the  external  iliac  itself.*  Thus,  ligature 
of  this  vessel  is  indicated  where  pressure,  rapid  or  gradual,  has  failed 
to  command  the  circulation,  where  it  is  intolerable,  where  it  cannot 
be  made  use  of  owing  to  the  abundance  of  fat,  from  failure  of  pulse 
and  breathing  under  an  anaesthetic,  or  from  the  height  at  which  the 
aneurism  involves  the  external  iliac,t  where  the  patient  from  chronic 
bronchitis  is  quite  unfit  for  a  prolonged  trial  of  continuous  pressure 
under  an  ana?sthetic,  or  in  cases  where  the  increase  of  the  aneurism 
is  very  rapid. 

Before  deciding  on  relinquishing  the  idea  of  pressure  for  ligature, 
the  surgeon  should  refer  to  a  paper  by  Mr.  Wheelhouse  (Clin.  Soc. 
Trans.,  vol.  vii.  p.  57).  This  case  is  one  of  the  most  interesting  in  all 
surgery.  The  patient,  a  publican,  and  syphilitic,  had  previously  been 
cured  by  Mr.  Wheelhouse  of  a  right-sided  popliteal  aneurism,^  by 

*  Mr.  Holmes  (R.CS.  Lect. :  Lancet,  1873,  vol.  i.)  shows  that  In  ilio-femoral  aneu- 
risms it  is  often  very  dilEcult  to  say  whether  the  aneurism  is  or  is  not  limited  to  the 
iliac  or  femoral — i.e.,  whether  it  is  wholly  above  or  below  the  place  where  the  deep 
epigastric  and  circumflex  iliac  come  off,  or  whether  the  mouths  of  these  vessels  open  out 
of  the  sac.  In  the  former  case  the  aneurism  would  be  purely  iliac  or  femoral;  in  the 
latter,  ilio-femoral. 

f  It  being  increasingly  difficult  to  apply  pressure  in  these  cases  without  dangerous 
interference  with  the  peritoneum  and  its  contents. 

X  It  is  very  possible  that  the  strain  thrown  on  the  artery  above  during  the  treatment 
by  pressure  on  the  femoral  was  the  cause  of  the  aneurism  higher  up.     The  liability 


LIGATURE    OF    THE    EXTERNAL    ILIAC.  629 

means  of  continuous  pressure  for  eight  hours  with  a  Porter's  femoral 
compressor.  A  few  months  later  he  was  admitted  into  the  Leeds 
Infirmar}^  with  a  large  right  iliac  aneurism  *  reaching  from  Poupart's 
ligament  to  within  2  inches  of  the  umbilicus,  and  extending  outwards 
almost  to  the  spine  of  the  ilium.  The  swelling,  about  the  size  of  a 
small  cocoanut,  was  hard  and  firm  below,  soft  above ;  it  app^red  to 
be  wholly  connected  with  the  external  iliac,  but  to  extend  above  and 
overlie  the  common  iliac.  Pressure  could  not  be  made  on  the  latter 
vessel  sufficient  to  stop  the  beating,  as  the  tumor  was  too  much  in 
the  way,  but  it  was  easily  controlled  by  pressure  on  the  abdominal 
aorta.  The  patient  was  kept  under  the  influence  of  ether  for  five 
hours,  Lister's  tourniquet  being  very  slowly  screwed  down  just  over 
the  umbilicus.  By  the  end  of  the  time  the  patient  was  black  in  both 
limbs,  and  blue  as  far  as  the  tourniquet.  This  had  been  slightly 
relaxed  twice.  No  other  unpleasant  symptoms  arose  during  the  whole 
time.  A  quarter  of  an  hour  was  taken  in  relaxing  the  pressure — a 
quarter  turn  of  the  handle  being  made  every  minute.  The  tumor  had 
ceased  to  pulsate  and  was  firm  and  hard.  Pulsation  gradually 
recurred  with  nearly  its  old  force,  but  was  less  "  distensile,"  and 
slowly  ceased  altogether,  an  excellent  recovery  being  made. 

In  the  same  volume  of  the  Clinical  Society's  Transactions  (p.  56)  is 
a  case  of  a  large  diffuse  femoral  aneurism,  in  which  Mr.  Barnard  Holt 
made  use  of  continued  pressure,  by  means  of  tourniquets  applied 
alternately  to  the  external  and  common  iliacs,  the  pressure  being  kept 
up  for  fifty -two  hours,  with  varying  alterations  of  the  tourniquets,  and 
intervals  of  consciousness  (for  about  half  an  hour)  to  allow  of  the 
patient  taking  brandy,  Liebig,  and  arrowroot.f   Chloroform  was  given 

of  patients  with  one  aneurism  to  develop  another  may  often  baffle  the  surgeon.  Mr. 
Glutton  {Brit.  Med.  Journ.,  1880,  vol.  i.  p.  441)  records  a  case  in  which  a  femoral  aneu- 
rism was  cured  by  the  use  of  Esmarch's  bandage  applied  up  to  the  tumor,  and  a  P^tit's 
tourniquet  adjusted  over  the  brim  of  the  pelvis.  The  first  attempt  lasted  an  hour;  at 
the  second  trial  the  Esmarch  was  removed  in  an  hour,  and  the  tourniquet  continued 
for  nine  hours,  anaesthetics  not  being  given.  The  aneurism  ceased  to  pulsate  and  began 
to  shrink,  but  still  fluctuated.  Nine  days  after  leaving  the  hospital,  the  patient  died 
suddenly  of  an  aortic  aneurism  rupturing  into  the  pericardium. 

*  Dr.  Diver,  of  Southsea,  has  put  on  record  a  case  in  which  the  external  iliac  was  tied 
in  a  case  in  which  a  popliteal  and  inguinal  aneurism  coexisted  on  the  right  side.  Gan- 
grene followed,  a  line  of  demarcation  forming  in  the  lower  third  of  the  leg.  Amputation 
through  the  thigh  was  performed,  and  the  patient  recovered.  A  similar  case  of  double 
aneurism  is  reported  by  Mr.  Hilton  (Med.  Chir.  Trans.,  vol.  ii.  p.  309).  A  tourniquet 
was  first  applied  to  the  right  common  iliac  for  six  hours  without  effect  on  the  aneu- 
risms. A  second  trial  of  pressure  was  made,  later  on,  with  a  tourniquet  again  on  the 
common  iliac  and  one  on  the  femoral  at  the  apex  of  Scarpa's  triangle.  In  about  nine 
hours  both  aneurisms  were  cured.     Chloroform  was  used  on  both  occasions. 

t  If  sickness  occurs  with  the  anaesthetic,  nutrient  enemata  should  be  given. 

34 


530  OPERATIONS  ON  THE  ABDOMEN. 

throughout,  and  cure  seems  to  have  been  probable ;  the  last  report 
being  that  "the  patient  left  the  hospital,  walking  well  with  the  aid 
of  one  crutch."* 

In  ruptured  f  femoral  aneurism  the  old  operation  (facilitated  by 
the  application  of  a  tourniquet  above)  would  usually  be  indicated, 
but  Mi^  Southam  has  briefly  reported  I  a  case  in  which  he  tied  the 
external  iliac  successfully  in  a  patient  whose  femoral  aneurism  sud- 
denly ruptured  and  became  diffuse.  The  effused  blood  wae  quickly 
absorbed,  and  there  was  never  any  tendency  to  gangrene.  Complete 
power  over  the  limb  was  regained. 

2,  Wounds. — A  wound  of  the  external  iliac  is  so  rare  as  to  be  almost 
unknown. §  It  has  been  frequently  tied  for  haemorrhage  from  parts 
below — e.g.,  for  secondary  haemorrhage  after  wounds  of  the  femoral 
high  up,  after  ligature  of  the  femoral,  and  after  amputation  at  or  near 
the  hip.    The  futility  ||  of  this  treatment  is  shown  by  a  table  in  which 


*  Cases  of  Dr.  Mapotlier's  and  Mr.  Holden's,  in  which  ilio-femoral  aneurisms  were 
cured  by  pressure  on  the  common  iliac  and  the  aorta,  will  be  found,  recorded  by  Dr. 
Mapother,  in  the  Dub.  Med.  Press,  March  '19,  1865,  and  by  Mr.  Holden,  in  St.  Barthol. 
Hosp.  Reports,  vol.  ii.  p.  190;  Syd.  Soc.  Bien.  Eetr.,  1865-6,  pp.  306,  307.  In  Dr. 
Mapother's  case,  instrumental  pressure  on  the  right  common  iliac  (about  1  inch  below 
and  2  inch  to  the  right  side  of  the  umbilicus)  kept  up  for  twelve  hours  under  chloro- 
form had  failed.  A  second  attempt,  with  a  Signorini's  tourniquet  on  the  end  of  the 
abdominal  aorta,  and  a  Skey's  tourniquet  on  the  femoral  just  as  it  left  the  sac,  pressure 
being  kept  up  for  four  hours  and  a  half,  made  the  tumor  solid  and  pulseless.  Two 
rigors  followed,  and  a  carbuncle  formed  at  the  site  of  the  first  compression.  In  Mr. 
Holden's  patient  the  aneurism  was  also  large,  and  double  aortic  valvular  disease  was 
present.  Chloroform  was  given  here  continuously  for  an  hour  and  a  half,  and  then 
with  cautious  intermissions,  owing  to  the  state  of  tlie  pulse  and  breathing,  for  the  rest 
of  the  treatment,  which  lasted  four  hours. 

f  In  an  interesting  case  recorded  by  Dr.  Sheen  of  Cardiff  {Brit.  Med.  Journ.,  1882, 
vol.  ii.  p.  720),  the  femoral  aneurism,  for  which  the  external  iliac  was  tied  success- 
fully, changed  its  shape  suddenly,  having  burst  some  of  its  coats,  apparently,  but  not 
all,  on  the  day  of  operation. 

X  Brit.  Med.  Journ,  1883,  vol.  i.  p.  818. 

^  The  only  case  with  wliich  I  am  acquainted  is  one  quoted  by  Mr.  Erichsen  from 
Velpeau  {Nouv.  EUm.  de  Med.  Oper.,  t.  i.  p.  175),  in  which  the  above  French  surgeon 
was  suddenly  called  upon  to  tie  the  external  iliac  for  a  knife-wound.  Though  there 
had  been  no  preliminary  dilatation  of  the  collateral  circulation,  either  by  pressure  or 
by  the  presence  of  an  aneuiism,  the  result  was  successful. 

II  It  is  fair  to  state  that  Mr.  Bartleet,  of  Birmingham,  published  a  case  in  which  the 
external  iliac  was  tied  successfully  after  secondary  hemorrhage  from  the  common 
femoral,  the  latter  having  been  tied  for  aneurism  of  the  femoral  artery.  Previous  to 
ligature  of  the  external  iliac,  "  sponge-pressure"  and  pressure  by  means  of  a  Martin's 
bandage  were  tried,  but  no  details  are  given.  It  is  noteworthy  that  the  catgut  ligature 
applied  to  the  femoral  in  this  case  came  away  on  the  seventh  day  (the  first  dny  of  the 
haemorrhage)  uuabsorbed,  and  surrounding  a  small  slough  of  the  artery.  It  had  been 
tied  "  tightly." 


LIGATURE   OF   THE    EXTERNAL    ILIAC.  531 

Dr.  Otis*  gives  a  summary  of  twenty-six  cases  in  which  the  external 
iliac  was  tied  for  such  cases  as  the  above.  Of  these,  twenty-three 
ended  fatally,  a  mortality  of  88.4  per  cent.  The  uselessness  of  trust- 
ing to  ligature  of  the  external  iliac  in  such  cases,  instead  of  either 
securing  the  wounded  vessel  itself,  or  trusting  to  Avell-applied  pressure, 
was  long  before  this  insisted  on  by  Guthrie.f  This  question  is  alluded 
to  again  below,  but  in  proof  of  the  above  statement  one  of  the  Ameri- 
can cases  X  may  be  mentioned  here,  in  which  ha'morrhage  returned 
after  ligature  of  the  external  iliac  and  was  arrested  by  well-applied 
pressure.  The  patient  had  been  wounded,  January  15,  1865,  by  a 
minie  ball,  entering  at  the  upper  and  inner  part  of  the  thigh,  and 
emerging  near  the  knee.  The  wound  becoming  sloughy,  haemorrhage 
occurred  from  the  wound — March  23  and  31 — and  the  external  iliac 
was  tied.  April  21.  Haemorrhage  recurred  from  the  ujDper  gun-shot 
wound,  and  was  successfully  restrained  by  a  horseshoe  tourniquet, 
constantly  kept  on  for  two  weeks,  when  it  was  omitted,  without  any 
subsequent  ha?morrhage.  The  wounds  were  now  healing  kindly,  when 
— May  31 — dysentery  set  in,  carrying  off  the  patient,  June  15,  two 
and  a  half  months  after  the  operation  of  ligature. 

3.  Elephantiasis. — Ligature  of  the  external  iliac  or  femoral  (when 
the  condition  of  the  soft  parts  admit  of  it)  has  been  extolled  by  some 
surgeons  in  the  treatment  of  this  affection. §  A  larger  experience 
shows,  however,  that  when  cases  thus  treated  are  watched,  the  cures 
cannot  be  relied  upon  as  permanent.  Moreover,  too  little  value  has 
been  attached,  in  reported  cures  by  ligature  of  the  main  vessel,  to  the 
thorough  rest  and  elevated  position  entailed  by  tying  the  artery. || 

*  Med.  and  Surcf.  History  of  the  War  of  the  Rebellion,  pt.  iii.  p.  788. 
t  Wounds  and  Injuries  of  the  Arteries,  Lects.  v.  and  vi. 
X  Otis,  loc.  supra  cii.,  p.  40, 

I  An  apparently  successful  case  is  reported  by  Mr.  Leonard,  of  Bristol.  Measure- 
ments are  given  nearly  three  years  after  tlie  operation,  showing  that  the  success  was 
then  maintained.  Five  years  later  the  patient  reported  that  "his  leg  was  much  the 
same"  as  at  the  last  report.  Bandaging  does  not  appear  to  have  been  made  use  of 
here.  Prof.  Buchanan  {Brit.  Med.  Journ.,  November  23,  1867;  Syd.  Soc.  Bien.  Betr., 
1867-8,  p.  300)  reports  a  case,  seven  months  after  the  operation,  apparently  cured  by 
ligature  of  the  external  iliac,  after  failure  of  rest  and  methodical  compression  (this  was 
before  the  introduction  of  Martin's  bandage).  Three  months  later  it  is  candidly  stated 
that  the  disease  liad  recurred  to  a  considerable  degree.  Dr.  White,  of  Harvard  Uni- 
versity {Intern.  Encycl.  of  Surg.,  vol.  ii.  p.  631),  quotes  Wernher  (reference  not  given) 
as  having  followed  up  thirty-lwo  cases  ;  in  all  there  was  an  immediate  reduction  of  size, 
but  the  relief  was  permanent  in  three  only.  Dr.  Pinnock,  of  Melbourne  {-Lancet,  1879, 
vol.  i.  p.  44),  gives  a  case  in  whicli  no  permanent  benefit  followed  on  ligature  of  the 
femoral  artery. 

II  A  severe  case  of  Mr.  Whitehead's  is  briefly  reported  in  the  Brit.  Med.  Journ., 
1882,  vol.  ii.  p.  1043.  The  disease  had  lasted  seventeen  years,  and  had  been  associated 
with  attacks  of  erysipelas.    "The  treatment  (successful)  had  consisted  in  rest,  massage, 


632 


OPERATIONS  ON  THE  ABDOMEN. 


This  operation  should,  I  think,  be  reserved  for  those  cases  (which 
will  be  very  few)  in  which  Martin's  bandages  cannot  be  applied  owing 
to  cracks,  foul  ulcers,  or  burrowing  sinuses.  Here  the  ligature  may- 
be used  after  explaining  its  risks  to  the  patient,  but  only  as  a  subsidi- 
ary measure.  The  bandage  will  have  to  be  used  as  well  later,  and 
persisted  in,  during  the  day  at  least,  probably  for  life. 

4.  As  a  distal  operation  in  aneurism  of  the  common  iliac,  ligature 
of  the  external  iliac,  has  been  so  unsuccessful  here  as  to  call  for  no 
further  comment. 

Surgical  Anatomy. 

Extent. — From  the  lumbo-sacral  articulation  to  a  point  just 
internal  to  the  centre  of  Poupart's  ligament  Length. — About  4 
inches. 

SuEFACE  Marking. — From  a  point  an  inch  below  and  to  the  left  of 
the  umbilicus  to  a  point  just  internal  to  the  centre  of  Poupart's 
ligament. 

Relations. 

In  Front. 
Peritoneum,  small  intestines. 
Iliac  fascia. 

Lymphatic  glands  and  vessels. 
Genito-crural  nerve  (genital  branch). 


Spermatic  vessels 
Circumflex  iliac  vein 

Outer  Side. 

Psoas  (above). 

Iliac  fascia. 


Crossing  artery  near  Poupart's  liga- 
ment. 

Inner  Side. 
External  iliac  Iliac  fascia, 

artery.  Vein, 


Behind. 
Iliac  fascia. 
Vein  (above). 
Psoas  (below). 


Vas  deferens  (dipping 
from  internal  ring 
to  pelvis). 


Collateral  Circulation. 

Deep  epigastric  with 

Deep  circumflex  iliac         with 
Gluteal  and  sciatic  with 

Comes  nervi  ischiadici       with 


Internal  mammary  and  lower 
intercostal  and  lumbar. 

Ilia-lumbar,  lumbar,  and  glu- 
teal. 

Internal -and  external  circum- 
flex. 

Perforating  branches  of  pro- 
funda. 


elastic  pressure,  compression  of  the  femoral  artery,  and  rubbing  down  the  tubercles  with 
pumice-stone.  The  knee,  which  had  become  flexed  and  ankylosed  by  bony  union,  was 
straightened  by  sawing  through  the  site  of  the  original  joint." 


IvIGATURE    OF   THE    EXTERNAL    ILIAC.  533 

Obturator  with  Circumflex  arteries   and   epigas- 

tric. 
Internal  pudic  with  External  pudic. 

Operation. — (1)  By  the  lower  and  more  transverse  incision  of  Sir 
A.  Cooper.  (2)  By  the  higher  and  more  vertical  incision  of  Abernethy. 
The  two  are  compared  at  p.  535. 

(1)  Incision  of  Sir  A.  Cooper. — This  is  the  method  more  frequently 
made  use  of.  The  diet  having  been  limited,  and  the  bowels  having 
been  freelj'-  moved  for  some  days  before  the  operation,  the  parts  shaved 
and  the  hip  slightly*  flexed,  an  incision  is  made  4  inches  long  (4i  to 
5  if  there  be  very  much  fat,  or  if  the  parts  are  pushed  up  by  a  con- 
tiguous aneurism),  parallel  with  Poupart's  ligament,  and  nearly  an 
inch  above  it,  commencing  just  outside  the  centre  of  the  ligament  and 
extending  outwards  and  upwards  beyond  the  anterior  superior  spine.f 
The  superficial  fascia  and  fat,  varying  in  amount,  being  divided,  and 
the  superficial  circumflex  iliac  vessels  secured,  the  external  oblique 
both  fleshy  and  aponeurotic  is  cut  through,  and  then  the  fleshy  fibres 
of  the  internal  oblique  and  transversalis.  This  is  done  either  by  using 
the  knife  alone,  lightly  and  carefully,  or  by  taking  up  each  layer  with 
forceps,  nicking  it,  and  slitting  it  up  on  a  director.  If  the  wound  be 
sponged  carefully,;};  a  layer  of  cellular  tissue  can  usually  be  seen  be- 
tween the  muscles  however  thin  they  are.  Any  muscular  branches 
should  be  secured  with  Spencer  Wells'  forceps  as  soon  as  cut;  and  in 
pushing  a  director  beneath  the  muscles  as  little  damage  as  possible 
should  be  done,  owing  to  the  proneness  to  cellulitis  later  on,  and  to 
the  proximity,  in  a  thin  patient,  of  the  peritoneum.  The  fascia  trans- 
versalis when  exposed,  will  be  found  to  vary  a  good  deal  in  thickness 
and  in  the  amount  of  fat  which  it  contains.  It  is  to  be  divided  very 
carefully ,§  and  the  extra-peritoneal  fat,  if  present,  will  next  come  into 


*  So  tliat  the  skin  may  not  be  too  much  relaxed  before  being  incised.  Later  on  to 
relax  the  parts,  the  hips  may  be  more  strongly  flexed. 

t  The  incision  may  have  to  be  made  higher  than  usual,  owing  to  the  upward  exten- 
sion of  the  aneurism,  to  enable  the  surgeon  to  tie  either  the  upper  part  of  the  external 
or  the  common  iliac.  On  this  point  see  the  remarks  on  the  comparison  of  Cooper's 
and  Abernethy's  operation,  p.  535.  Often  in  these  cases  of  upward  extension  of  the 
aneurir5m  the  sac  is  found  to  involve  the  lower  part  of  the  artery,  and  to  have  over- 
lapped the  upper  portion. 

X  In  some  cases  where  the  circulation  has  been  much  interfered  with  by  an 
aneurism,  most  copious  haemorrhage,  especially  venous,  has  been  met  with  in  the 
earlier  steps  of  this  operation. 

§  Dr.  Sheen  {Inc.  supra  cit.)  thus  writes  of  the  accident  which  may  happen  here : 
"  I  made  the  incision  somewhat  too  high,  and,  in  consequence,  opened  the  peritoneum, 
which  I  mistook  for  transversalis  fascia.  Even  then  I  was  in  a  little  doubt,  because 
some  (omental)  fat  presented  itself,  which  very  much  resembled  the  fat  seen  in  the 


534 


OPERATIONS  ON  THE  ABDOMEN, 


view.  First  one  and  then  two  fingers  being  introduced,  the  peritoneum 
is  to  be  gently  stripped  up  from  the  iliac  fossa  towards  the  middle  line 
— i.e.,  upwards  and  inwards  as  far  as  the  inner  border  of  the  psoas.* 
In  doing  this,  care  must  be  taken,  especially  in  the  dead  body,  not  to 
separate  the  iliac  fascia  and  the  vessels  from  their  position  on  the 

Fig.  93. 


Ligature  of  the  external  iliac  artery.  Tlie  peritoneum  is  held  out  of  the  way  above  and  at  the 
two  angles  of  the  wound.  Below  are  seen,  from  without  inwards,  theiliacus,  psoas,  genito-crural 
nerve,  the  artery  (with  a  ligature  beneath  it),  and  the  vein. 

The  incision  below  is  that  for  ligature  of  the  commou  femoral. 


psoas,  not  to  tear  this  muscle,  and  not  to  lacerate  the  peritoneum.  As 
soon  as  the  peritoneum  has  been  well  raised,  an  assistant  keeps  this 
and  the  upper  lip  of  the  wound  well  out  of  the  way  by  means  of  broad 
retractors.     The  surgeon  then  feels  for  the  pulsation  of  the  artery  on 

previous  case  (fat  around  the  vessel),  but  in  pushing  this  up  gently,  a  knuckle  of  bowel 
came  into  view,  which  settled  the  matter."  The  wound  in  the  peritonasum  was  sewn 
up  with  two  fine  carbolized  sutures,  and  the  case  did  perfectly  well. 

*  Great  care  is  needed  here  if  the  peritoneum  is  adherent.  This  condition,  when 
present,  is  usually  found  above.  It  is  especially  likely  in  long-standing  cases,  and 
where  the  aneurism  has  caused  irritative  and  inflammatory  clianges.  By  some  it  is 
held  that  the  transversalis  fascia  can  always  be  stripped  up  along  with  the  peritoneum. 
As  this  fascia  is  thickened  and  attached,  close  to  Poupart's  ligament,  to  form  the  deeper 
crural  arch  and  front  of  the  femoral  sheath,  it  is  very  doubtful  if  it  can  ever  be  de- 
tached unless  it  is  divided  or  torn  through.   The  latter  is  very  easy  on  an  aged  corpse. 


LIGATURE   OF    THE    EXTERNAL    ILIAC.  535 

the  inner  border  of  the  psoas,  and  carefully  opens  the  layer  of  fascia 
which  ties  the  vessel  to  the  psoas  and  forms  a  weak  sheath  to  it.  This 
should  be  done  li  inch  above  Poupart's  ligament,^  and  the  needle 
jDassed  from  within  outwards,  carefully  avoiding  the  vein  on  the  inner 
side  and  the  genito-crural  nerve  outside  and  in  front.  In  difficult 
cases  the  ligature  must  mainly  be  passed  by  touch,  but  a  free  incision, 
adequate  use  of  retractors,  and  light  thrown  in  by  a  large  mirror,  will 
very  often  allow  the  surgeon  to  see  what  he  is  doing.  The  effect  of 
tightening  the  ligature  being  satisfactory,  it  is  cut  short  and  dropped 
in,  the  cut  muscles  are  then  brought  together  with  chromic  gut  cut 
short,  sufficient  drainage  provided,  and  the  superficial  wound  closed. 
The  parts  must  be  kept  relaxed  by  propping  the  chest  up  slightly  and 
flexing  the  knees  over  a  pillow,  but  too  much  flexion  of  the  groin  is 
to  be  deprecated  as  causing  a  deep  sulcus  from  which  discharges  will 
escape  with  difficulty.  The  limb  is  evenly  bandaged  from  the  toes 
upwards,  raised  and  kept  covered  in  cotton  wool,  with  hot  bottles 
placed  in  the  bed.f  In  case  of  threatening  gangrene,  assistants  should 
persevere  in  a  trial  of  friction  of  the  limb  from  below  upwards.  Where 
there  is  a  history  of  syphilis,  appropriate  remedies  should  be  given 
after  the  operation. 

(2)  Incision  of  Abernethy. — In  his  first  operation  this  surgeon 
made  his  incision  in  the  line  of  the  artery  for  about  three  inches,  com- 
mencing nearly  4  inches  above  Poupart's  ligament.  Later  on  he 
modified  his  incision  by  making  it  less  vertical,  and  more  curved,  with 
its  convexity  downwards  and  outwards,  and  extending  between  the 
following  points — viz.,  one  about  1  inch  internal  and  1  inch  above  the 
anterior  superior  spine  to  I2  inch  above  and  external  to  the  centre  of 
Poupart's  ligament. 

The  respective  advantages  and  disadvantages  of  the  methods 
of  Cooper  and  Abernethy  appear  to  be  the  following :  Cooper's  is  rather 
the  easier,  interfering  as  it  does  with  the  peritoneum  less,  and  lower 
down.  It  is  most  suitable  to  those  cases  which  do  not  extend  far,  if 
at  all,  above  Poupart's  ligament.  The  risk  of  ventral  hernia  would 
appear  to  be  less.  On  the  other  hand,  where  the  extent  to  which  the 
aneurism  reaches  upwards  is  not  exactly  known,  Abernethy 's  opera- 
tion, hitting  off  the  artery,  as  it  does,  higher  up,  or  some  modification 
of  that  given  (p.  547)  for  ligature  of  the  common  iliac  will  be  found 
preferal>le. 

Difficulties  and  Possible  Mistakes. 

1  Too  short  an  incision.     Here,  as   in  colotomy  and  other  deep 


*  So  as  to  lie  well  above  the  origin  of  the  deep  epigastric,  which  usually  comes  off 
J  or  5  inch  above  Poupart's  ligament.  The  absence  of  any  other  branch  should,  if 
possible,  be  verified. 

f  If  the  patient  be  restless,  as  in  delirium  tremens,  a  long  splint  should  be  applied. 


536  OPERATIONS  ON  THE  ABDOMEN. 

operations  on  the  abdominal  wall,  every  layer  must  be  cut  to  the  full 
extent  of  the  superficial  ones.  Otherwise  the  operator  will  be  working 
at  the  bottom  of  a  conical,  confined  wound. 

2.  A  wrongly  placed  incision — i.e.,  one  which,  by  going  too  near  the 
middle  line,  opens  the  internal  abdominal  ring,  or  which,  if  too  low, 
may  come  too  near  the  cord. 

3.  Disturbing  the  planes  of  cellular  tissue  needlessly  or  roughly. 

4.  Wounding  the  peritoneum,  owing  to  a  hasty  incision  through  a 
thin  abdominal  wall,  by  rough  use  of  a  director,  especially  if  the 
peritoneum  is  adherent  in  the  neighborhood  of  the  sac,  or  fixed  with 
the  transversalis  fascia.  The  peritoneum  is  often  difficult  to  dis- 
tinguish :  it  is  bluish  in  aspect,  but  of  course  not  smooth,  but  covered 
with  cellular  tissue  which  connects  it  to  the  extra-peritoneal  fat. 

5.  Stripping  up  the  peritoneum  roughly  and  too  far. 

6.  Detaching  the  artery  from  the  psoas. 

7.  Lacerating  the  psoas. 

8.  Tying  or  injuring  the  vein. 

9.  Including  the  genito-crnral  nerve. 

10.  An  abnormal  position  of  the  artery.  This  may  be  due  to  an 
exaggeration  of  that  naturally  tortuous  condition  of  the  artery  which 
is  especially  likely  to  be  met  with  in  patients  advanced  in  life. 
Another  unusual  cause  of  displacement  may  be  met  with  in  extrava- 
sated  blood,  when  an  aneurism  has  given  way.  Sir  W.  Fergusson 
briefly  reported  (Brit.  Med.  Journ.,  1873,  vol.  i.  p.  286)  an  instance  of 
this  kind,  in  which  the  sac  gave  way  after  repeated  manipulation. 
Much  venous  ha3morrhage  was  met  with  during  the  first  incisions  and 
evidence  of  extravasated  blood  deeper  down.  On  reaching  the  peri- 
toneum, a  novel  feature  presented  itself.  Instead  of  the  iliacus*  lying 
uninjured  before  the  operator,  it  seemed  as  if  the  aneurism  had  burst 
at  the  back,  and  a  great  infiltration  of  blood  had  taken  place  into  the 
substance  of  the  iliacus.  No  trace  of  the  artery  could  be  seen,  nor 
could  it  be  felt  anywhere.  On  pushing  his  finger  deeply  in  towards 
the  middle  line  close  upon  the  bladder.  Sir  W.  Fergusson  came  upon 
the  artery,  with  little  pulsation  and  quite  at  the  inner  side  of  the 
swollen  ilicacus.  Pulsation  in  the  aneurism  ceased  as  soon  as  the 
ligature  was  tightened.     How  the  case  ended  is  not  stated. 

Causes  of  Failure  and  Death. 

1.  Gangrene.  In  some  cases,  where  the  limb  does  not  become 
gangrenous,  the  vitality  is  very  feeble  and  requires  much  attention. 
Thus,  in  Mr.  Rivington's  case  (Clm.  Soc.  Trans.,  vol.  xix.  p.  45),  loss  of 
sensation  was  noticed  on  the  fourth  day,  followed  by  paralysis  of 
most  of  the  muscles.     Though  gangrene  did  not  appear,  and    the 

*  Probably  the  ilio-psoas  is  intended  here. 


LIGATURE   OF   THE   EXTERNAL   ILIAC.  537 

patient  survived  five  and  a  half  months,  the  limb  was  "  on  the  verge 
of  gangrene,"  as  shown  by  sores  appearing  on  the  heel  and  great  toe  * 

2.  Secondary  haemorrhage.  This  is  especially  likely  if  the  wound 
becomes  septic,  and  if  catgut  is  used.  This  fatal  result  may  be  long 
deferred ;  thus,  in  Mr.  Rivington's  case  {loc.  supra  cit),  the  patient  died 
of  secondary  haemorrhage  five  and  a  half  months  after  the  operation ; 
the  wound  had  been  found  septic  at  the  first  dressing,  catgut  was 
used.  Early  recurrence  of  pulsation  may  be  ominous  of  secondary 
haemorrhage.  In  a  case  of  Sir  A.  Cooper  the  haemorrhage  which 
proved  fatal  a  fortnight  after  the  operation  was  found  to  be  due  to 
a  large  collateral — viz.,  an  abnormal  obturator  arising  immediately 
above  the  site  of  ligature  (Roux,  Parallele  de  la  Chir.  Anglaise  avec  la 
Chir.  Francaise,  etc.,  pp.  278,  279). 

3.  Cellulitis.  Septicaemia.  Pyaemia.  Owing  to  the  number  of 
planes  of  cellular  tissue  met  with  here,  any  needless  or  rough  disturb- 
ance of  the  parts,  inadequate  drainage,  or  a  septic  condition  super- 
vening, are  extremely  to  be  deprecated.  The  wound  should  be 
opened  up  at  once  if  any  collection  of  fluid  is  suspected. 

4.  Peritonitis. 

5.  Tetanus,  from  including  the  genito-crural  nerve. 

6.  Phlebitis  and  secondary  haemorrhage  from  injury  to  the  external 
iliac  vein. 

7.  Suppuration  of  the  sac  with  its  attendant  dangers  of  septic  in- 
fection and  secondary  haemorrhage.f 

This  accident  is  far  from  uncommon  in  cases  of  inguinal  aneurism 
after  ligature.  No  pains  should  be  spared  to  prevent  its  occurrence 
by  taking  every  step  to  keep  the  wound  strictly  aseptic  from  first  to 
last,  and  thus  to  secure  early  and  sound  healing.  Absolute  rest 
should  also  be  enforced  upon  the  patient.  If  suppuration  take  place 
it  will  usually  be  wdthin  two  months  of  the  date  of  ligature.  The 
symptoms  need  not  be  alluded  to  here  beyond  pointing  out  that 
pulsation  is  one  of  very  grave  omen.  When  it  is  evident  that  suppu- 
ration, if  not  established,  is  inevitable,  the  surgeon  should  so  arrange 
his  time  as  to  choose  a  suitable  occasion  both  as  to  assistance  and 
a  good  light,  for  interfering.  Allowing  the  suppurating  sac  to  open 
spontaneously  should  not  be  thought  of,  not  only  because  of  the  risk 
of  haemorrhage,  the  want  of  preparation,  etc.,  but  because  septic  in- 

*  In  one  of  Dr.  Sheen's  cases  already  referred  to,  four  days  after  the  operation  a 
large  patch  of  skin  on  the  outer  side  of  the  thigh  was  noticed  to  be  darkish  in  color, 
and  to  pit  on  pressure,  though  normal  as  to  sensation.     The  case  did  quite  well. 

t  Very  occasionally  secondary  haemorrhage  may  take  place  to  a  slight  amount,  and 
leave  off  spontaneously.  Thus,  in  one  of  Dr.  Sheen's  cases,  five  weeks  after  the  opera- 
tion "  about  an  ounce  of  bright-red  blood  came  from  the  slight  remaining  wound,  and 
a  slight  oozing  again  after  a  few  days,  but  there  was  no  further  haemorrhage." 


538  OPERATIONS    ON    THE    ABDOMEN. 

fection  is  now  made  very  probable.  The  operative  steps  are  much 
the  same  as  in  the  old  operation  for  aneurism,  for  which  the  reader  is 
referred  to  p.  554.  It  maj'-  be  here  pointed  out  that  in  this  case  there 
is  more  chance  of  the  htemorrhage  taking  the  form  of  a  general  oozing 
from  the  sac,  and  not  that  of  a  gush  or  spirt  of  blood.  INIoreover,  if 
the  collateral  circulation  has  been  well  established,  there  is  also  the 
probability  of  the  sac  being  fed  by  some  additional  branch,  which, 
perhaps,  entering  deep  down,  may  be  a  cause  of  much  embarrassment. 

8.  Recurrence  of  pulsation. 

This  is  especially  likely  to  occur  when  a  catgut  ligature  has  been 
used  and  given  way,  owing  to  its  being  softened  by  suppuration. 
Over-free  collateral  circulation  will  cause  recurrence  of  pulsation 
quickly,  and  melting  down  of  soft  coagulum  (this  appearing  to  be  all 
that  the  blood  can  do  in  the  way  of  clotting)  will  bring  about  the 
same  cause  of  failure  later  on. 

In  these  cases,  the  following  courses  are  open  in  the  matter  of  the 
external  iliac — viz.,  well-adjusted  and  carefully  maintained  pressure, 
and  the  old  operation.  Ligature  of  the  vessel  lower  down — i.e.,  between 
the  first  and  the  aneurism — and  amputation  are  not  available  here.* 

Two  other  conditions  which  may  supervene  and  prove  troublesome 
should  be  mentioned  here,  viz. : 

9.  Formation  of  a  ventral  hernia.  This  should  be  prevented  as  far  as 
possible  by  ensuring  primary  union,  and  by  the  use  of  deep  chromic 
gut  sutures  in  the  cut  muscles.  Later  on,  if  this  complication  occur, 
an  appropriate  belt  should  be  worn. 

10.  Coming  away  of  the  ligature  long  after  the  operation  through  a 
persistent  sinus  or  reopened  wound.  This  may  happen,  even  in  a 
wound  kept  sweet  from  first  to  last,  if  a  silk  ligature  has  not  been 
properly  carbolized,  or  if  one  of  too  close  texture  is  used.  See  the 
foot-note,  p.  404, 

LIGATURE  OF  THE  COMMON  ILIAC   (Fig.  94). 

Indications. — Very  few : 

1.  Aneurisms.  Especially  those  inguinal  aneurisms  which  affect 
the  external  iliac  on  its  upper  part,  above  the  origin  of  the  deep  epi- 
gastric, occupying  the  iliac  fossa  and  lower  part  of  the  abdomen. 
When  such  aneurisms  are  progressing  steadily,  when  they  have  re- 

*  In  one  case  [Syd.  Soc.  Bien.  Retr.,  1873-4,  p.  220)  after  ligature  of  the  external 
iliac  for  a  femoral  aneurism  with  catgut,  and  premature  absorption  of  this  on  the  fifth 
day  (the  wound  suppurated  freely,  and  antiseptic  precautions  do  not  appear  to  have 
been  taken),  pulsation  returned,  and  the  swelling  enlarged.  The  patient  was  operated 
upon  again,  and  a  stout  carbolized  hempen  ligature  made  use  of,  one  end  being  left 
long.  Though,  owing  to  the  close  matting  of  parts,  the  peritoneum  was  wounded 
twice,  and  intestines  and  omentum  protruded,  the  patient  recovered. 


LIGATURE   OF   THE   COMMON    ILIAC.  539 

sisted  a  trial  of  pressure,  and  are  not  thought  amenable  to  the  old 
operation,  ligature  of  the  common  iliac  is  indicated. 

The  following  remarks  by  one  of  the  chief  living  authorities  on 
aneurism,  Mr.  Holmes,*  will  aid  the  surgeon  in  coming  to  a  decision 
in  this  most  important  matter : 

"Allowing  that  an  iliac  aneurism  is  amenable  to  all  three  methods 
of  treatment,  the  Hunterian,  by  ligature  of  the  aorta  or  common 
iliac ;  the  old  operation,  by  laying  open  the  sac  and  securing  the 
artery  or  arteries  opening  into  and  out  of  it ;  and  the  method  of  com- 
pression applied  to  the  aorta  or  common  iliac — I  think  no  one  could 
deny  that  the  number  of  cures  by  the  latter  method  bears  a  very 
large  proportion  to  the  number  of  cases  treated,  while  the  cures  by 
the  Hunterian  method  are  very  rare,  and  the  other  method  is  as  yet 
pretty  nearly  untried. 

"  But  this  is  far  from  settling  the  question  ;  compression,  doubtless, 
often  succeeds,  but  it  also  often  fails.  It  is  not  without  its  risks.  It 
usually  requires  the  prolonged  use  of  chloroform,  and  this  cannot 
always  be  borne  by  the  patient. 

"  The  question  of  applying  the  old  method  in  preference  to  the 
Hunterian  in  those  cases  (rare,  it  may  be,  but  which  must  sometimes 
be  met  with)  in  which  pressure  has  failed,  is  one  which  Mr.  Syme's 
brilliant  operations  have  put  in  a  totally  new  light.  And  I  must  say, 
for  my  own  part,  that  looking  at  the  awful  mortality  which  has 
attended  the  ligature  of  the  common  iliac  for  aneurism,  and  the  uni- 
form fatality  of  the  same  operation  on  the  aorta,  I  think  Mr.  Syme's 
suggestion  ought  to  be  put  to  the  test  of  more  extended  experience, 
although  the  facts  and  reasonings  which  I  have  adduced  will  show 
that  I  am  not  insensible  lo  the  risks  which  attend  the  performance 
of  the  operation,  to  the  probability  of  secondary  haemorrhage,  and  to 
the  extensive  injury  which  must  be  inflicted  upon  parts  in  the  imme- 
diate neighborhood  of  important  organs." 

Mr.  Holmes,  then,  in  proof  of  the  great  fatality  of  the  Hunterian 
operation  on  the  common  iliac,  quotes  the  list  collected  by  Dr.  Stephen 
Smith,t  in  which,  out  of  fifteen  cases  in  which  that  vessel  was  tied  for 
aneurism,  only  three  can  be  reckoned  as  definitely  cured. 

Mr.  Holmes's  belief  that  subsequent  experience  has  not  been  more 
favorable,  is  supported  by  a  table  of  65  cases,  tabulated  by  Dr.  Pack- 
ard.;}: Of  these  65  cases,  no  fewer  than  51  died,  only  14  recovering, 
giving  a  general  mortality  of  78.46  per  cent,  § 

*  R.C.S.  Lectures  {Lancet,  1873,  vol.  i.  p.  297). 

t  Amer.  Journ.  Med.  Sci.,  July,  1860,  vol.  xl. 

X  Trans.  Amer.  Surg.  Assoc.,  vol.  i.  p.  234,  Sixty-seven  cases  are  given,  but  the 
result  is  not  slated  in  two. 

I  Grouping  these  cases  into  classes,  after  Dr.  Smith's  example,  in  cder  to  obtain 
more  satisfactory  deductions,  Dr.  Packard  concludes  as  follows:  (i)  Those  cases  in 


540  OPERATIONS   ON    THE    ABDOMEN. 

Mr.  Holmes  goes  on  to  discuss  the  old  operation,  and  in  answer  to 
the  objection  that,  though  the  Hunterian  operation  has  been  attended 
with  "  awful  mortality  "  here,  we  are  not  made  more  secure  by  oper- 
ating on  an  artery,  perhaps  not  much  more  than  3  inches  lower  down, 
and  already  involved  in  disease,  writes :  "  I  reply,  that  if  we  grant  the 
artery  where  it  is  involved  in  the  sac  to  be  healthy  enough  to  bear  the 
ligature,  many  advantages  may  be  found  in  the  old  operation  over 

that  of  Hunter First,  the  clot  is  removed,  and  the  sac  laid 

open ;  consequently,  that  softening  of  clot  and  inflammation  of  a 
closed  sac  lying  in  proximity  to  the  peritoneum,  which  is  so  surely 
fatal,  is  obviated.  Next,  the  ligature  will  probably  be  placed  on  the 
external  iliac  instead  of  the  common,  and  thus  the  chances  of  gan- 
grene will  be  greatly  diminished,  since  the  internal  iliac  and  its 
branches  are  left  open.  Thirdly,  the  artery  is  tied  at  a  point  where 
most  likely  the  peritoneum  and  viscera  have  been  pushed  away  from 
it  by  the  sac,  so  that  there  is  less  risk  of  hurtful  interference  with  these 
latter  in  the  operation.  And,  lastly,  the  total  excision  of  the  tumor 
precludes  any  such  relapse  as  occurs  sometimes  after  the  Hunterian 
operation. 

"  Against  these  advantages  must  be  set  the  undoubted  risks  of  sec- 
ondary haemorrhage,  even  in  cases  where  the  immediate  dangers  of 
the  operation  have  been  surmounted.  What  this  risk  is  we  have  no 
means  of  judging  until  our  experience  of  this  operation  becomes 
greater ;  but  I  am  under  the  impression  that  Mr.  Syme  much  under- 
rated it,  in  consequence  of  having  operated  chiefly  upon  traumatic 
aneurism." 

Farther  on,*  Mr.  Holmes  writes,  while  "  maintaining  that  the  old 
doctrine  on  which  the  suj^eriority  of  Hunter's  operation  is  based,  is 
quite  true  in  general,  I  should  have  no  objection  in  the  particular  in- 
stance of  iliac  aneurism,  to  follow  Mr.  Syme's  practice ;  at  least  until 
further  experience  of  it  should  show  that  it  is  wrong :  only  the  less 
dangerous  expedient  of  rapid  compression  of  the  trunk-artery  under 
chloroform,  or  gradual  compression,  with  or  without  chloroform, 
should  first  be  tried." 

The  same  authority  when,  later  on,  discussing  the  value  of  pressure, 
brings  out  the  following  facts.     That  while  rapid  compression  under 

which  the  operation  was  done  for  the  arrest  of  hseraorrhage:  22  cases,  of  whicli  19 
died  and  3  recovered;  mortality,  86.86  per  cent,  (ii)  Those  in  wiiich  it  was  done  for 
the  cure  of  anenrism ;  35  cases,  of  which  24  died  and  9  recovered,  tiie  result  not  being 
stated  in  2;  mortality  in  33  cases,  72.72  per  cent,  (iii)  Those  cases  in  which  tumors 
simulating  anenrism  led  to  its  performance:  5  cases,  4  of  which  died  and  1  recovered. 
(iv)  Those  in  which  the  vessel  was  secured  to  prevent  haemorrhage  during  the  removal 
of  a  morbid  growth  :  3  cases,  all  of  which  died. 
*  Loc.  supra  cil.,  p.  367. 


LIGATURE    OF    THE    COMMON    ILIAC.  541 

chloroform  is  a  mode  of  treatment  by  which  most  gratifying  success 
has  been  obtained  in  iliac  as  well  as  aortic  aneurism,  it  exposes  the 
patient  to  serious  dangers.  Amongst  these  are  enteritis  and  peritonitis 
from  bruising  of  small  intestine,  mesentery,  meso-colon,  and  sympa- 
thetic ;  hsematuria ;  failure  of  pulse  and  breathing  when  the  pad  is 
screwed  down.  On  account  of  these  very  real  dangers,  which  every 
dexterity  may  not  obviate,  Mr.  Holmes  advocates  a  trial  of  gradual 
compression,  as  safer,  though  less  efficient,  and  he  points  out  that  the 
relations  of  the  common  iliac  are  le^s  complicated  than  those  of  the 
aorta,  and,  "  as  we  get  further  to  one  side  there  is  more  chance  for  the 
intestines  to  slip  out  of  the  way."* 

2.  Wounds.  These  maj^  be  gunshot  or  bayonet  wounds,  or  knife 
stabs  of  the  vessel  itself,  or  the  internal  iliac  or  its  branches,  usually 
the  latter.  The  haemorrhage  calling  for  ligature  seems  to  be  usually 
secondary .f  Gunshot  wounds  of  the  common  iliac  have  a  fresh  in- 
terest now,  owing  to  the  recent  advances  in  surgery  in  the  treatment 
of  gunshot  wounds  of  the  abdomen. 

Dr.  S.  Smith  J  gives  two  cases  of  ligature  of  the  common  iliac  for 
wounds,  the  one  from  a  musket-ball  which  injured  the  vessel  itself, 
passed  through  the  intestines  and  lodged  in  the  sacrum.  The  opera- 
tion was  performed  by  opening  the  peritoneal  cavity.  Peritonitis  soon 
set  in ;  secondary  haemorrhage  recurred  repeatedly,  and  the  case  ended 
fatally  on  the  fifteenth  day.  The  other  case  is  of  great  interest,  as  the 
common  and  internal  iliac  were  here  tied  for  severe  haemorrhage  after 
a  stab  in  the  inguinal  region.  A  large  quantity  of  blood  was  found  in 
the  peritoneal  cavity,  and  the  patient  died  ten  hours  after  the  operation. 
At  the  autopsy  it  was  found  that  the  deep  epigastric  was  the  wounded 
vessel. 

Dr.  Otis§  records  four  cases  of  ligature  of  the  common  iliac  during 
the  late  American  war.  In  one,  a  gunshot  wound,  in  which  the  ball 
entered  the  groin  and  came  out  at  the  buttock,  the  external  iliac  was  first 
tied,  the  repeated  haemorrhage  being  believed  to  be  from  the  profunda,, 
but  as  the  bleeding  persisted  and  evidently  came  from  the  sciatic,  the 
wound  was  prolonged  and  the  common  iliac  tied.     Both  ligatures 

*  Mr.  Holmes  draws  attention  also  to  this  most  important  point — i.e.,  that  rapid  co- 
agulation in  an  anenrismal  tumor  cannot  be  regarded  as  in  itself  a  means  of  cure,  but 
only  as  the  commencement  of  a  process  which,  if  not  interrupted,  may  result  in  cure, 
and  that  thus,  while  pulsation  may  diminish  soon  after  a  trial  of  compression,  it  may 
not  absolutely  cease  for  quite  a  month. 

t  It  would  naturally  be  thought  that  haemorrhage  from  a  wound  of  the  common  iliac 
would  be  fatal  before  a  ligature  could  be  applied.  Dr.  Otis  gives  a  case  in  which  this 
vessel  was  wounded  by  a  ball  entering  from  the  buttock  through  the  sacro  iliac  syn- 
chondrosis.    Death  took  place  from  hsemorrhage  on  the  second  day. 

X  Amer.  Journ.  Med.Sci.,  1860,  vol.  xl.  p.  17. 

I  Med.  and  Surg.  History  of  the  War  of  the  Rebellion,  pt.  ii.  p.  333. 


542  OPEEATIONS  ON  THE  ABDOMEN, 

came  away,  and  the  operation-wound  healed,  but  the  patient  died 
about  three  months  later  of  exhaustion,  associated,  apparently,  with 
necrosis  in  the  gluteal  region. 

In  the  second  case  the  common  iliac  was  tied  for  a  gunshot  wound 
believed  to  be  of  the  gluteal  artery,  in  which  the  hemorrhage  was  not 
arrested  by  tying  the  internal  iliac.  The  haemorrhage  recurred  and 
death  took  place  two  days  later.  The  third  case  was  one  of  diffuse 
aneurism  of  the  right  buttock  and  iliac  fossa  resulting  from  a  bayonet 
stab  in  the  former  region.  Death  took  place  four  days  later  from 
gangrene  of  the  sac.  The  old  operation  is  considered  by  Dr.  Otis  to 
have  been  preferable  in  this  case,  but  as  the  post-mortem  showed  that 
the  anterior  trunk  of  the  internal  iliac  had  been  wounded,  within  the 
sacro-sciatic  notch,  by  the  bayonet,  it  is  difficult  to  see  how  the  case 
could  have  been  treated  save  by  ligature  of  the  internal  iliac,  either 
outside  or  within  the  peritoneum,  and  then  by  opening  and  filling  the 
aneurismal  sac  with  aseptic  gauze  or  sponges.  The  fourth  case  was 
one  of  aneurismal  varix  of  the  femoral  vessels  from  a  punctured 
wound  2  inches  below  Poupart's  ligament.  In  this  case,  owing  to  the 
impossibility  of  separating  the  peritoneum,  this  was  incised  and  the 
common  iliac  thus  secured.  Peritonitis  proved  fatal  four  days  later. 
Here  ligature  of  the  artery  lower  down,  above  and  below  the  original 
seat  of  injury,  would  have  been  better  treatment. 

3.  For  the  arrest  of  haemorrhage  apart  from  aneurism.  Such  cases 
may  be  met  with  after  amputation  near  the  hip,  followed  by  secondary 
hemorrhage  from  the  branches  of  the  internal  iliac  in  what  is  usually 
the  i^osterior  flap. 

Mr.  Listen*  published  a  case  of  this  kind  in  which,  after  amputa- 
tion below  the  trochanter  minor  for  necrosis  of  the  femur,  haemorrhage 
occurred  from  the  stump  on  the  seventh  day.  As  this  could  not  be 
arrested  the  common  iliac  was  tied,  but  the  patient  died  twenty-four 
hours  later. 

Dr.  Packard  f  treated  a  somewhat  similar  case  in  the  same  way,  suc- 
cessfully. This  case  is  especially  interesting  as  the  ha?morrhage  oc- 
curred from  branches  of  the  internal  iliac  after  a  Furneaux  Jordan's 
amputation,  a  method  which  is  coming  largely  into  vogue  now,  and 
which  would  usually  be  expected  to  do  away  with  the  above  risk. J 
Haemorrhage  occurred  from  the  stump  on  the  sixth  day,  and  as  this 
could  not  be  arrested  by  pressure  the  common  iliac  was  tied.  The 
patient  ultimately  did  well. 

*  Lond.  Med.  Gaz.,  April  24,  1830. 

f  Loc.  supra  cit.,  foot-note,  p.  539. 

X  In  Dr.  Packard's  case  the  Furneaux  Jordan's  amputation  was  performed  probably 
higher  up  than  usual,  owing  to  osteo-myeiitis,  after  a  previous  amputation  for  growth 
at  about  the  middle  of  the  thigh. 


LIGATURE   OF    THE    COMMON    ILIAC.  543 

It  will  not,  it  is  hoped,  seem  a  hasty  criticism  on  the  above  if  I  say 
that  in  future  cases  opening  up  the  flaps  and  plugging  with  aseptic 
gauze,*  or  the  application  for  some  days  of  Spencer  Wells's  forceps, 
aided  by  even  pressure  on  the  flaps  and  pressure  on  the  common  or 
external  iliac,  would  be  preferable  to  submitting  the  patient  to  the 
severe  and  risky  operation  of  ligature  of  the  common  iliac. 

4.  For  pulsating  tumors  simulating  aneurism.  As  these  growths 
from  the  iliac  fossa  and  the  walls  of  the  j^elvis  have  been  found  to  be 
malignant,  it  is  of  the  utmost  importance  to  form  a  correct  diagnosis 
in  these  cases,  and  thus  save  a  patient  who  has  a  certainly  fatal  dis- 
order from  being  submitted  to  an  operation  which  is  most  dangerous 
and  almost  certain  to  be  useless.f  As  mistakes  have,  however,  been 
made  in  these  cases  by  excellent  surgeons,^  the  chief  points  of  diag- 
nosis, as  given  by  Mr.  Holmes, §  may  be  briefly  mentioned  here  :  (1) 
The  bruit  is  usually  less  well  marked  ;  (2)  The  pulsation  is  less  heav- 
ing and  less  expansive ;  (3)  The  condition  of  the  bone  with  which  the 
swelling  is  connected ;  thus,  a  plate  of  bone  may  be  found  in  the 
supposed  aneurismal  sac;  the  supposed  aneurism  may  be  found  both 
on  the  gluteal  and  the  iliac  aspects  of  the  pelvis,  the  bone  being  ex- 
panded by  the  growth  ;  (4)  The  cancerous  cachexia  is  usually  present, 
and  perhaps  secondary  growths  as  well. 

5.  For  haemorrhage,  not  the  result  of  a  wound.  Ligature  of  the 
common  iliac  has  been  employed  in  some  cases  of  this  nature,  usually 
secondary  haemorrhage  after  ligature  of  the  external  iliac,  the  gluteal 
and  sciatic,  or  after  rupture  of  the  external  iliac.  Ligature  of  the 
main  trunk  has  been  so  fatal  in  these  cases  that  it  ought  to  be  aban- 
doned, carefully  applied  pressure  aided  by  plugging  with  aseptic 
gauze,  or  the  old  operation  being  certainly  preferable. 

Mr.  Morrant  Baker  has  put  on  record  ||  a  case  of  great  interest  in 
diagnosis,  in  which  an  abscess  from  sacro-iliac  disease  ulcerated  into 
branches  of  the  internal  iliac  artery,  and  when  opened  gave  rise  to 
hsemorrhage  calling  for  ligature  of  the  common  iliac :  A  gardener, 
aged  seventeen,  had  felt  pain  a  month  previously  while  digging.  A 
tense,  elastic  swelling,  distinctly  fluctuating,  and  acutely  tender,  occu- 

*  Wrung  out  of  turpentine  if  the  ])arts  are  sloughy  (p.  423). 

f  In  Guthrie's  case,  a  pulsating  tumor  in  the  right  buttock,  the  size  of  an  adult 
head,  diminished  by  one-half  in  a  month.  Two  months  later  it  again  enlarged,  and 
the  patient  dying,  eight  months  after  the  operation,  an  immense  encepluiloid  tumor 
was  found  occupying  the  right  iliac  region. 

X  ^.(/..Guthrie  (Lnnd.  Med.  Gaz.,  vol.  ii.  1834);  Stanley  (Hied.  Chir.  Trans.,  vol. 
xxviii.) ;  Moore  {ibid.,  vol.  xxxv.). 

?  Syst.  of  Surg.,  vol.  iii.  pp.  44,  145.  The  reader  should  also  consult  Mr.  Holmes's 
article,  "  On  Pulsating  Tumors  which  are  not  Aneurismal,  and  on  Aneurisms  which 
are  not  Pulsating  Tumors"  (St.  Georges  Hasp.  Reports,  vol.  vii.). 

II  St.  Barthol.  Hosp.  Eeps.,  vol.  viii.  p.  120. 


544  OPERATIONS  ON  THE  ABDOMEN. 

piecl  all  the  right  buttock.  It  was  opened,  and  a  small  stream  of 
apparently  arterial  blood  escaped  without  jets.  On  further  explora- 
tion the  finger  entered  a  large  cavity  between  the  iliac  bone  and  the 
glutei.  The  iliac  fossa  was  full  and  tense,  and  on  examination,  per 
rectum,  a  swelling  was  found  in  the  right  ischio-rectal  fossa.  On 
enlarging  the  gluteal  wound  a  steady  stream  of  arterial  blood  welled 
up  through  the  great  sacro-sciatic  foramen.  This  was  firmly  plugged 
and  the  common  iliac  tied.  On  removing  the  plug  some  bleeding 
still  occurred,  but  was  easily  arrested.  The  gluteal  wound  became 
offensive,  and  this  region,  together  with  the  upper  part  of  the  thigh, 
became  gangrenous,  the  leg  and  foot  remaining  unaffected.  The 
patient  died  forty  hours  after  the  operation. 

Post  mortem  the  sacro-iliac  joint  was  open  and  the  neighboring 
bone  diseased.  The  remains  of  a  large  abscess  was  found  involving 
the  branches  of  the  internal  iliac.     There  was  no  trace  of  aneurism. 

Surgical  Anatomy. — The  common  iliacs  coming  off  on  the  left 
side  of  the  fourth  lumbar  vertebra,  incline  downwards  and  outwards 
to  divide,  opposite  to  the  lumbo-sacral  intervertebral  disk,  into  the 
internal  and  external  iliacs.  The  right  is  rather  the  longer  and  more 
oblique  of  the  two.  Their  length  is  usually  H  inch.  Their  branches 
are  few  and  small — viz.,  to  the  ureter,  psoas  muscles,  glands,  etc.  The 
iliacs  become  increasingly  tortuous  with  age  :  a  point  of  importance  in 
tying  the  vessel  on  an  aged  corpse. 

Line. — One  drawn  from  a  point  I2  inch  below  and  a  little  to  the 
left  of  the  umbilicus  to  the  centre  of  Poupart's  ligament,  the  line 
curving  a  little  outwards  in  its  couise,  will  represent  the  course  of  the 
artery  with  sufficient  accuracy. 

Guide. — The  above  line  is  the  only  surface  guide :  more  deeply  the 

lumbo-sacral  articulation  and  the  psoas  muscles  are  useful  guides, 

especially  in  a  thin  subject.* 

Relations  : 

In  Front. 

Peritoneum ;  small  intestine ;  caecum  and 

appendix,  sometimes. 
Ureter. 
Sympathetic. 

Outside.  Inside. 

Psoas.  Left  common  iliac  vein. 

Vena  cava. 

T, .   1  ,  Right  common 

Right  common  i,^^^  ^^.^^^y. 

iliac  vein. 

*  Attention  has  been  drawn  to  the  need  of  employing  touch,  as  well  as  sight,  in  the 
ligature  of  these  large  trunks  (p.  534). 


ligature  of  the  common  iliac.  545 

Behind. 

Right  and  left  common  iliac  vein. 

In  Front. 
Peritoneum  ;  small  intestine. 
Sympathetic. 
Ureter. 

Superior  hajmorrhoidal  artery.     Rectum. 
Outside. 

Psoas.  Left  common 

iliac  artery. 

Behind. 
Left  common  iliac  vein. 

Collateral  Circulation. — The  chief  vessels  concerned  here  are : 

Above.  Below. 

Internal  mammary  and 

Deep  epigastric. 
Ilio-lumbar  and  circumflex 

iliac. 
Lateral  sacral. 
Inferior  and  middle  ha?m- 
orrhoidal. 

In  addition,  the  pubic  arteries  anastomose  behind  the  symphysis. 

Operations  (Fig.  94). — The  common  iliac  may  be  tied  by  opera- 
tions based  upon  one  of  two  incisions.  (1)  An  anterior  abdominal  by 
which  the  vessel  is  approached  more  directly  from  the  front ;  an  in- 
cision based  upon  those  for  tying  the  external  iliac,  and  made  use  of 
by  Dr.  Mott,  of  New  York,  who  first  tied  this  vessel  in  1827.  (2)  A 
posterior  abdominal,  or  loin  incision,  by  which  the  vessel  is  reached 
from  behind  ;  a  method  made  use  of  by  Sir  P.  Crampton,  of  Dublin,  in 
1828,  and  by  Mr.  Stanley  at  St.  Bartholomew's,  in  1846  (.Fig.  94). 

(1)  Anterior  Abdominal  Incision. — The  preparatory  treatment  is  here 
the  same  as  that  for  the  external  iliac.  The  parts  being  shaved  and 
cleansed,  a  curved  incision,  5  to  8  inches  long,  according  to  the  amount 
of  fat,  the  development  of  the  body,  and  the  size  of  the  aneurism,  is 
made,  commencing  just  outside  the  centre  of  Poupart's  ligament  and 
Ij  inch  above  it,  then  carried  outwards,  reaching  towards  the  crest  of 
the  ilium,  then  upwards  towards  the  ribs,  and  finally  curving  inwards 
towards  the  umbilicus,  till  sufficiently  free  to  admit  of  the  necessary 
manipulations  for  reaching  the  artery.  The  three  abdominal  muscles 
are  cut  through,  either  on  a  director,  or  with  careful,  light  sweej^s  of 

35 


hnver  intercostals, 

with 

Lumbar, 

with 

Middle  sacral, 

with 

Superior  hemorrhoidal, 

with 

546  OPERATIONS  ON  THE  ABDOMEN. 

the  knife,  till  the  fiiscia  transversalis  is  reached ;  any  vessels  which 
bleed  *  being  at  once  secured  with  Spencer  Wells's  forceps.  The  fascia 
transversalis,  which  may  generally  be  known  from  the  peritoneum 
by  the  layer  of  extra-peritoneal  fat,  which  usually  intervenes  between 
the  two,  is  then  picked  up  and  divided  on  a  director,  at  the  lower  part 
of  the  wound  where  it  is  best  marked.f  The  peritoneum  is  next  raised 
upwards  and  inwards,  first  one  finger,  and  then  more,  being  insinuated 
towards  the  middle  line  until  the  psoas  is  reached.  On  the  inner  side 
of  this  muscle  the  artery  will  be  found,  the  external  iliac  being  traced 
up  if  needful.  In  order  to  aid  the  surgeon  in  the  difficulties  which 
are  now  met  with,  owing  to  the  artery  lying  at  the  bottom  of  a  very 
deep  wound,  the  abdominal  walls  should  be  relaxed  by  bending  up 
the  thighs,  the  wound  sponged  thoroughly  dry,  and  light  thrown  in 
by  a  reflector  if  needful.  Care  will,  of  course,  have  been  taken  to 
divide  every  layer  from  end  to  end  equally,  and  thus  to  avoid  a  coni- 
cal hole  of  a  wound.  The  position  of  the  vessel  having  been  made 
out,  it  is  to  be  cleaned  with  a  director,  especial  care  being  taken  on 
the  right  side,  as  here  both  the  common  iliac  veins  lie  behind  the 
artery.     The  needle  should  be  passed  from  within  outwards. 

(2)  Posterior  Incision,  partly  in  Abdomen,  partly  in  Loin.  —  This 
operation  will  be  best  given  in  the  words  of  Sir  P.  Crampton,^  who 
first  introduced  it : 

"  The  first  incision  §  commenced  at  the  anterior  extremity  of  the 
last  false  rib,  proceeding  directly  downwards  to  the  ilium ;  it  followed 
the  line  of  the  crista  ilii,  keeping  a  very  little  within  its  inner  margin, 
until  it  terminated  at  the  superior  anterior  spinous  process  of  that 
bone ;  the  incision  was  therefore  chiefly  curvilinear,  the  concavity  look- 
ing towards  the  navel.  The  abdominal  muscles  were  then  divided  to 
the  extent  of  about  an  inch,  close  to  the  superior  anterior  spinous  pro- 
cess, down  to  the  peritoneum ;  into  this  wound  the  forefinger  of  the 
left  hand  was  introduced,  and  passed  slowly  and  cautiously  along 
the  line  of  the  crista  ilii,  separating  the  peritoneum  from  the  fascia 
iliaca.  A  probe-pointed  bistoury  was  now  passed  along  the  finger  to 
its  extremity,  and  by  raising  the  heel  of  the  knife,  while  its  point 
rested  firmly  at  the  end  of  the  finger  as  on  a  fulcrum,  the  abdominal 
muscles  were  separated  from  their  attachments  to  the  crista  ilii  by  a 
single  stroke.  By  repeating  this  manoeuvre  the  wound  was  prolonged 
until  sufficient  room  was  obtained  to  pass  down  the  hand  between 
the  peritoneum  and  the  fascia  iliaca.     Detaching  the  very  slight  con- 

*  See  note,  p.  533. 

f  Dr.  Liddell  {Intern.  Encyd.  of  Surg.,  vol.  iii.  p.  312)  recommends  that  the  separa- 
tion of  this  fascia  from  the  peritoneum  should  be  begun  at  the  upper  part  of  tiie  wound, 
where  the  adhesion  is  slightest. 

X  Med.  Chir.  Trans.,  vol.  xvi.  p.  161. 

§  The  patient  would,  of  course,  be  rolled  over  on  to  the  sound  side. 


LIGATURE   OF    THE   COMMON    ILIAC. 


547 


nections  which  these  parts  have  with  each  other,  I  was  able  to  raise 
up  the  peritoneal  sac  with  its  contained  intestines  on  the  palm  of  my 
hand,  from  the  psoas  magnus  and  iliacus  and  internus  muscles,  and 
thus  obtain  a  distinct  view  of  all  the  important  parts  beneath ;  and 
assuredly  a  more  striking  view  has  seldom  been  presented  to  the  eye 
of  the  surgeon  ;  the  parts  were  unobscured  by  a  single  drop  of  blood  ; 
there  lay  the  great  iliac  artery,  nearly  as  large  as  my  finger,  beating 
awfully,  at  the  rate  of  two  in  a  minute,  its  yellowish-white  coat  con- 
trasting strongly  with  the  dark  blue  of  the  iliac  vein  which  lay  beside 
it,  and  seemed  nearly  double  its  size ;  the  ureter  in  its  course  to  the 
bladder  lay  like  a  white  tape  across  the  artery,  but  in  the  process  of 
separating  the  peritoneum,  it  was  raised  from  it  with  that  membrane 
to  which  it  remained  attached.     The  fulness  of  the  iliac  vein  seemed 

Fig.  94. 


Ligature  of  common  iliac  by  a  posterior  incision.    This  would  also  be  available  for  the 
abdominal  aorta.    (Bryant.) 

to  vary  from  time  to  time,  now  appearing  to  rise  above  the  level  of 
the  artery,  and  now  to  subside  below  it.  Nothing  could  be  more  easy 
than  to  pass  a  ligature  round  an  artery  so  situated.  The  forefinger  of 
the  left  hand  was  passed  under  the  artery,  which,  with  a  little  man- 
agement, was  easily  separated  from  the  vein;  and  on  the  finger 
(which  served  as  a  guide)  a  common-eyed  probe,  furnished  with  a 
ligature  of  moistened  catgut,  was  passed  under  the  vessel.  A  sur- 
geon's knot  was  made  in  the  ligature,  and  the  noose  gradually  closed, 
until  ]Mr.  Colles,  who  held  his  hand  pressed  upon  the  tumor,  an- 
nounced that  all  pulsation  had  ceased.  A  second  knot  was  then 
made,  and  one  end  of  the  ligature  cut  oflf  short,"     Unfortunatelv,  the 


548  OPERATIONS    OX    THE    ABDOMEN. 

catgut  of  that  day  became  quickly  dissolved,  pulsation  returned  in 
the  tumor  within  fifty  hours  of  the  operation,  and  on  the  tenth  day 
profuse  secondary  haemorrhage  took  place,  death  following  imme- 
diatel^y. 

Comparison  of  the  Two  Methods.— Sir  P.  Crampton  thus 
speaks  of  his  own  and  Dr.  Mott's  operation  :  "  The  operation  of 
tying  the  common  iliac  artery  is  not  only  a  feasible  but  (when  per- 
formed in  the  manner  described  in  this  paper)  an  exceedingly  easy 
operation.  The  difiiculties  which  Dr.  Mott  encountered,  and  which 
prolonged  the  operation  to  nearly  an  hour,*  are  clearly  referable  to 
the  circumstance  of  his  incision  having  been  made  too  low.  This,  in 
the  first  place,  brought  him  in  contact  with  the  aneurismal  tumor, 
from  which  he  was  obliged,  with  great  labor  and  considerable  risk,  to 
detach  the  peritoneum ;  then  he  had  the  whole  mass  of  the  tumor 
between  him  and  the  artery  which  he  was  to  tie;  and,  lastly,  he  had 
the  intestines  pressing  down  upon  him  and  producing  such  a  compli- 
cation of  difficulties  as  I  believe  few  men  but  himself  could  have 
encountered  with  success." 

Mr.  Skey t  preferred  the  posterior  incision  for  these  reasons:  (1) 
It  is  a  part  less  liable  to  consequent  inflammation.  (2)  The  requisite 
separation  of  the  peritoneum  is  less  extensive.  (3)  The  artery  is 
brought  better  into  view,  the  act  of  passing  the  needle  around  it  being 
made  visible  to  observers  around.  (4)  The  line  of  the  vessel  is 
sufficiently  exposed  to  enable  the  operator  to  select  his  site  of  liga- 
ture, to  carry  it  higher  or  lower,  or  even,  if  necessary,  to  separate  the 
l^eritoneum  from  the  aorta  itself,  and  to  pass  a  ligature  around  that 
vessel  at  a  sufficient  distance  from  its  bifurcation.  (5)  The  formation 
of  a  ventral  hernia  is  not  likely  to  occur. 

To  the  above  Mr.  Skey  might  have  added  that  the  posterior  incision 
gives  far  better  drainage  to  the  wound. 

The  difficulties  of  the  operation  and  the  causes  of  failure 
and  of  death  are  much  the  same  as  those  already  given  in  the 
account  of  ligature  of  the  external  iliac  (pp.  585,  6o6). 

LIGATURE  OF  THE  INTERNAL  ILIAC. 

Indications. — Very  few  and  rare. 

i.  In  some  cases  of  gluteal  and  sciatic  aneurisms.  Mr.  Holmes,  in 
the  course  of  those  lectures  from  which  I  have  already  quoted,  lays 
down  conclusions  which  will  very  greatly  help  the  surgeon  in  de- 
ciding what  form  of  treatment  is  best  suited  to  these  aneurisms. 
They  are  quoted  below  under  the  heading  of  Ligature  of  the  Gluteal 
Artery  (p.  552). 

*  Sir  P.  Crampton's  operation  was  completed  in  twenty.-two  minutes, 
f   Operative  Surgery,  p.  294. 


LIGATURE    OF    THE    INTERNAL    ILIAC.  549 

ii.  Htemorrhage.  This  is  most  frequently  met  with  in  military 
surgery  after  gun-shot  wounds  of  the  vessel  itself,  but  more  often  of 
one  or  more  of  its  branches  within  the  pelvis,  the  ball  entering  usually 
from  the  front  through  the  inguinal  region,  or  behind  through  the 
sacrum.  Four  such  cases  are  given  by  Dr.  Otis,*  all  being  fatal. 
Two  cases,  in  which  this  artery  was  tied  for  wounds  of  the  sciatic 
and  gluteal  respectively,  are  given  by  the  above  writer  {op.  cit.,  p.  332) ; 
both  were  fatal  from  haemorrhage. 

Dr.  Liddelljt  who  as  U.S.A.  Medical  Inspector,  saw  much  of  mili- 
tary surgery,  gives  the  following  advice  in  case  of  punctured  wounds 
of  this  artery  or  its  branches :  "  The  wound  should  be  explored  by 
introducing  a  finger  into  it  for  the  purpose  of  locating  by  touch  the 
precise  point  whence  the  blood  issues  by  jets  into  the  M'ound.  If  the 
punctured  artery  is  found  to  be  external  to  the  pelvis,  the  bleeding 
point  sliould  be  laid  bare  bj^  enlarging  and  cleansing  the  wound,  and 
the  vessel  secured  by  ligatures  placed  on  each  side  of  the  aperture. 
But  if  it  be  shown  by  the  occurrence  of  intra-pelvic  extravasation  of 
blood,  or  by  other  signs,  that  the  internal  iliac-artery,  or  some  branch 
thereof,  is  wounded  within  the  pelvis,  it  will  be  impossible  to  reach 
and  tie  the  punctured  artery  in  the  wound.  Under  these  circum- 
stances it  sometimes  becomes  ver}^  difficult  to  decide  what  plan  of 

treatment  should  be  adopted One  thing,"  Dr.  Liddell  goes  on 

to  say,  "  ought  never  to  be  done,  that  is,  trusting  to  the  use  of  iron 
perchloride  or  persulphate.  The  first  thing  to  be  tried,  in  most  cases, 
is  compression.  It  should  be  applied  to  the  common  iliac-artery, 
and,  at  the  same  time,  to  the  wound  itself,  if  possible,  with  a  view  to 
obtain  coagulation  of  the  blood  in,  and  obliteration  of,  the  wounded 
artery.  The  very  desperateness  of  these  cases  makes  it  all  the  more 
necessary  to  use  the  compression  faithfulh- .  intelligently,  and  persist- 
ently, otherwise  a  traumatic  aneurism  will  form." 

Surgical  Anatomy. — A  short  trunk  about  l-i  inch  long,  of  large 
size,  the  internal  iliac  given  off  opposite  to  the  lumbo-sacral  inter- 
vertebral disk  dips  downwards  and  backwards  as  far  as  the  upjiei 
part  of  the  sacro-sciatic  notch,  where  it  gives  off  its  anterior  and  pos- 
terior trunks,  a  ligamentous  cord  also  coming  off  from  the  bifurcation  : 
this  cord,  the  remains  of  the  obliterated  hypogastric  artery,  usually 
remains  pervious  as  far  in  the  bladder  as  one  of  the  vesical  arteries.. 

Line. — Xo  distinct  line  or  guide  can  be  given  for  this  vessel,  owing 
to  its  at  once  dipping  into  the  pelvis,  but  it  will  be  worth  while  to. 
remember  that  a  line  drawn  with  a  slight  curve  outwards  from  a 
point  about  an  inch  below,  and  a  little  to  the  left  of,  the  umbilicus,. 

*  Med.  and  Surg.  History  of  the  War  of  the  Rebellion,  pt.  Li.  p.  331. 
f  Intern.  Encycl.  of  Surg.,  vol.  iii.  p.  125. 


550  OPERATIONS    ON    THE    ABDOMEN". 

to  the  centre  of  Poupart's  ligament,  gives  sufficiently  accurately  the 
line  of  the  common  and  external  iliac  arteries  :  the  internal  is  given 
off  about  two  inches  from  the  commencement  of  this  line.* 

Relations  : 

In  Front. 
Ureter. 
Peritoneum. 
Rectum  (left  side). 
Outside.  Inside, 

Right  internal  iliac  vein.  Pyriformis, 

Obturator  nerve.  Internal  iliac.  Sacral  nerves. 

Behind. 
Internal  iliac  vein. 
Sacro-iliac  sj'nchondrosis. 
Lumbo-sacral  nerve. 

Operation. — The  preparatory  treatment  being  the  same  as  in 
ligature  of  the  external  iliac  (p.  533),  the  surgeon  makes  an  incision 
much  as  in  the  case  of  that  artery,  or  else,  in  the  words  of  Dr.  Stevens 
(who  first  tied  the  vessel  successfully  in  1812),  "  one  about  5  inches 
long,  parallel  with  the  deep  epigastric  artery,  and  nearly  ^  inch 
on  the  outer  side  of  it."  The  peritoneum  having  been  raised  up,  the 
hips  are  well  flexed,  and  the  lips  of  the  wound  retracted  as  widely 
as  possible :  the  finger  now  finds  the  external  iliac,  and  then  by  tracing 
it  up  the  internal  iliac  vessel. f  The  cord  of  the  obturator  nerve  must 
not  be  mistaken  for  this. J 

The  artery  is  now  separated,  partly  with  the  finger-nail  and  partly 
with  the  point  of  the  director,  and  the  needle  passed  from  within  out- 
wards, avoiding  the  vein  and  psoas  muscle.  It  will  be  well  to  have  in 
readiness  aneurism  needles  of  different  curves,  and  an  ordinary  silver- 
eyed  probe. 

Ligature  of  the  Internal  Iliac  by  Laparotomy. — This  method 
has  been  advocated  recently  by  Dr.  Dennis,§  of  New  York,  on  account 
of  the  following  advantages ;  (1)  Laparotomy  in  no  way  increases  the 
dangers  of  the  operation  of  ligature  of  the  internal  iliac.     (2)  Lapa- 

*  Tlie  origin  of  the  arteries  will  be  found  nearly  opposite  to  the  centre  of  a  line 
drawn  from  the  anterior  superior  spine  to  the  umbilicus. 

f  The  finger  should  be  passed  downwards  and  backwards  towards  the  sacro-iliac 
synchondrosis. 

X  In  cases  of  doubt  the  artery  should  be  compressed  gently  between  the  finger  and 
thumb. 

^  New  York  Med.  News,  November  20,  1886;  Annals  of  Surgery,  vol.  v.  No.  1,  p.  55. 
I  am  indebted  to  the  latter  periodical  for  the  above  account. 


LIGATURE    OF    THE    GLUTEAL    ARTERY.  551 

rotomy  prevents  a  series  of  accidents  which  have  occurred  during  the 
performance  of  the  operation  of  ligature  of  this  artery  by  the  older 
methods.  Amongst  these  are,  the  division  of  the  circumflex  and  epi- 
gastric arteries,  wounding  the  vas  deferens,  including  the  ureter  in  the 
ligature,  puncturing  the  iliac  or  circumflex  veins,  tying  the  genital 
branch  of  the  genito-crural,  tearing  the  peritoneum,  injury  to  the  sub- 
peritoneal connective  tissue,  cellulitis,  purulent  oedema,  pelvic  abscess, 
septicaemia,  and  pytemia.  (3)  Laparotomy  enables  the  surgeon  to  ap- 
ply the  ligature  at  a  point  of  election,  and  to  obtain  information  as  to 
the  exact  extent  of  disease  in  the  main  arterial  trunk.  (4)  Laparotomy 
occupies  much  less  time  for  its  perfurmance,  in  order  to  secure  the  in- 
ternal iliac,  than  was  occupied  by  the  older  methods. 

Three  cases  are  given  by  Dr.  Dennis,  two  of  which  occurred  in  his 
own  practice.  (A)  A  woman,  aged  sixty,  presented  pulsatile  tumors 
in  both  gluteal  regions,  the  tumors  dating  back  a  year  and  a  half,  and 
pain  three  years  back.  The  external  parts  being  thoroughly  purified, 
a  median  incision  was  made  from  the  umbilicus  to  the  pubes;  the 
pelvic  viscera,*  which  would  have  hindered  the  operation,  were  drawn 
out  into  warm,  moist  sponges  and  towels,  the  internal  iliacs  of  both 
sides  ligatured  with  catgut,  the  viscera  returned,  the  wound  closed,  and 
aseptic  dressing  supplied.  The  patient  died  with  suppression  of  urine, 
and  slight  parenchymatous  nephritis,  on  the  third  day.  (B)  A  negro, 
aged  forty-six,  had  a  right  gluteal  aneurism,  the  trouble  dating  back 
seven  months.  By  a  curved  lateral  incision  the  abdomen  was  opened  • 
owing  to  the  violent  efforts  of  the  patient,  and  the  difficulty  of  manip- 
ulation, a  few  coils  of  intestine  were  drawn  out,  a  strong  silk  ligature 
applied  to  the  internal  iliac,  the  ])arts  cleansed,  and  the  wound  closed, 
A  cure  followed.  (C)  A  female,  aged  eighteen,  had  an  aneurismal  varix 
of  the  left  side,  the  trouble  dating  back  many  years.  Under  careful 
antiseptic  treatment  the  abdomen  was  opened,  the  incision  finally  ex- 
tending from  the  symphysis  to  some  distance  above  the  umbilicus,  the 
intestines  drawn  out  sufficiently  to  admit  of  exposure  of  the  vessel,  a 
double  twisted  catgut  ligature  applied  to  the  left  internal  iliac,  the 
bowels  returned,  and  the  wound  treated  as  before.  The  patient  rallied 
quickW,  and  the  bowels  were  moved  normally  on  the  fifth  day  :  a  slight 
acute  albuminuria,  due  to  congestion  of  the  kidney  from  the  ligature 
of  the  main  trunk  of  the  internal  iliac,  appeared  on  the  following  day, 
but  soon  disappeared.  The  aneurism,  together  with  the  aneurismal 
varix,  was  perfectly  cured. 

LIGATURE  OP  THE  GLUTEAL  ARTERY. 
Indications. 

1.  Stab.  2.  Aneurism.  3.  Haniiorrhage  after  opening  an  abscess. 
All  are  rare,  especially  the  last. 

*  Probably  small  intestine  occupying  the  pelvis  is  intended  here. 


552  OPERATIONS   ON    THE    ABDOMEN. 

1.  Stab. — The  source  of  the  bleeding  from  a  stab  in  the  buttock  may 
be  very  difficult  to  tell  exactly.  The  surgeon  must  be  guided  by  the 
position  of  the  exit  of  the  gluteal  and  sciatic  (pp.  553,  555) ;  he  will 
remember  the  outline  of  the  gluteus  maximus,  the  lower  border  of  this 
muscle  forming  the  fold  of  the  buttock,  the  upper  starting  from  the 

-crest  about  2  inches  in  front  of  the  posterior  superior  spine,  and  run- 
ning downwards  and  forwards  to  the  great  trochanter.  Haemorrhage 
from  a  stab  in  the  upper  part  of  this  muscle  will  probably  come  from 
the  gluteal ;  if  from  the  lower  part,  from  the  gluteal  or  sciatic. 

2.  Aneurism. — This  affection  is  so  rare  that  it  will  be  sufficient  to 
quote  the  following  conclusions  of  Mr.  Holmes:* 

(1)  "  Gluteal  aneurisms,  both  traumatic  and  spontaneous,  are  very 
favorably  circumstanced  for  the  treatment  by  either  rapid  or  gradual 
compression,  applied  to  the  aorta  or  common  iliac."  Mr.  Holmes  points 
out  that  gluteal  aneurism,  if  not  ruptured,  is  usually  of  no  great  size, . 
and  does  not  encroach  upon  the  abdomen,  and  thus  any  part  of  the 
common  iliac  or  aorta  is  accessible  to  pressure. 

(2)  "  If  this  treatment,  with  or  without  anaesthetics,  does  not  succeed 
by  itself,  it  may  be  supplemented  by  coagulating  injection  or  galvano- 
puncture,  while  the  patient  is  narcotized,  and  the  circulation  com- 
manded."    Of  the  two,  Mr.  Holmes  prefers  galvano-puncture.f 

(3)  "  When  such  treatment  fails,  and  particularly  in  aneurisms  with 
imperfect  or  ruptured  sacs,  where  it  is  not  indicated,  the  internal  iliac 
must  be  tied  when  the  surgeon  thinks  that  he  cannot  find  the  artery 
outside  the  pelvis.  -  But  wlien  the  artery  is  accessible,  the  old  opera- 
tion, or  the  operation  of  Anel,  should  be  practiced,  according  to  the 
size  and  extent  of  the  tumor." 

In  deciding  whether  the  aneurism  is  inside  or  outside  the  jDclvis,  the 
surgeon  will  see  if  the  pulsation  can  be  commanded  by  pressure  on 
the  artery  above  the  aneurism,  whether  the  latter  can  be  lifted  frpm 
the  bone,  and  also  make  an  examination  by  vagina  or  rectum.^ 

The  old  operation  must  always  be  formidable,  and  while  modern 
tourniquets  may  admit  of  efficient  pressure,  there  is  always  the  risk 
of  fatal  hsemorrhage  from  the  artery  having  retracted  into  the  pelvis. 

The  method  of  Anel  does  not  seem  likely  to  be  always  useful:  of 
three  cases,  only  one  has  been  successful. 

(4)  "  The  ligature  of  the  internal  iliac  is  liable  to  failure  in  cases  of 
spontaneous  aneurism  from  a  diseased  condition  of  the  coats  of  the 
artery,  and  should  always  be  avoided  when  other  means  of  treatment 
are  available." 

*  Hunt.  Lect.,  Lancet,  1874,  vol.  ii.  p.  76;  Si/st.  of  Surg.,  vol.  iii.  p.  148. 
•!■  See  the  remarks  on  the  introduction  of  foreign  bodies  and  galvano-puncture,  pp. 
495,  497. 

X  An  aufesthetic  being  given,  and  the  liand  passed  here,  if  needful. 


LIGATURE    OF    THE   GLUTEAL    ARTERY. 


553 


This  method  has  proved  fatal  in  about  half  the  cases  operated  on. 
The  varying  length  of  the  artery,  the  proximity  of  the  ligature  in  all 
cases  to  large  branches  and  to  the  sac,  have  all  to  be  remembered. 

Surgical  Anatomy  of  Gluteal  Artery.— A  short,  thick  branch 
from  the  posterior  division  of  the  internal  iliac,  this  leaves  the  pelvis 
above  the  pyriformit.^,  through  the  sacro-sciatic  notch.  Immediately 
after  its  exit  it  divides  into  a  superficial  and  deep  portion.  The  super- 
ficial is  mainly  distributed  to  the  gluteus  maximus,  the  deep  lies  be- 
tween the  gluteus  raedius  and  minimus,  and  divides  into  two,  the 
upper  branch  running  along  the  origin  of  the  gluteus  minimus,  and 

Fig.  95. 


Ligature  of  the  gluteal  artery  Is  shown  above.  The  fibres  of  the  gluteus  maximus  have  been 
separated,  showing  the  raedius  beneath.  The  vessel  has  been  secured  close  to  the  great  sacro- 
sciatic  notch,  before  it  divides  into  a  superficial  and  deep  part.  The  latter  is  not  shown.  Below 
is  shown  the  incision  for  stretching  the  great  sciatic  nerve,  as  it  lies  under  cover  of  the  ham- 
strings. 

the  lower  running  obliquely  across  this  muscle  towards  the  trochanter 
major.  The  gluteal  nerve  emerges  just  below  its  artery,  and  sends 
branches  with  the  deeper  portion. 

LiXE  AND  Guide. — "  If  a  line  be  drawn  from  the  posterior  superior 
spine  to  the  great  trochanter,  the  limb  being  slightly  flexed  and  rotated 
inwards,  the  point  of  emergence  of  the  gluteal  artery  from  the  upper 
part  of  the  sciatic  notch  will  correspond  with  the  junction  of  the  upper 
with  the  middle  third  of  tliis  line  "  (MacCormdc,  Lig.  of  Arts.,  p.  126, 
Figs.  90  and  91). 

Operation. — The  patient  being  rolled  two-thirds  over  on  to  his 
face,  the  part  well  exposed  and  cleansed,  the  limb  hanging  over  the 


554  OPERATIONS   ON   THE   ABDOMEN. 

edge  of  the  table,  an  incision,  5  inches  long,  is  made  in  a  line  running 
from  the  posterior  superior  spine  to  the  upper  and  inner  part  of  the 
great  trochanter.  This  incision  should  run  almost  parallel  with  the 
gluteus  maximus.  The  fibres  of  this  muscle  being  separated,  between 
adjacent  fasciculi,  with  a  director,  a  muscular  branch  should  be  found 
and  traced  down  to  the  exit  of  the  artery.  The  gluteus  maximus  hav- 
ing been  relaxed,  and  the  contiguous  margins  of  the  gluteus  medius 
and  pyriforrais  separated  with  retractors,  the  surgeon,  taking  as  his 
guide  the  above  line  and  the  aperture  of  the  great  sacro-sciatic  notch, 
clears  the  arter}^  as  high  up  as  possible,  avoiding  the  nerve  and  the 
veins,  and  dividing  the  adjacent  muscles  if  needful.  The  ligature 
should  be  applied  as  far  within  the  notch  as  possible,  almost  within 
the  pelvis,  as  the  gluteal  divides  immediately  after  its  exit. 

Old  Operation. — The  following  is  the  account  of  Prof.  Syme's 
case.  The  man  had  been  stabbed  in  the  buttock  seven  j^ears  before. 
The  aneurism  measured  more  than  13  inches  in  botli  diameters ;  this, 
together  with  the  great  thinness  and  laxity  of  the  coverings  being 
opposed  to  coagulation,  led  to  the  adoption  of  the  old  operation. 
"  The  patient  having  been  rendered  unconscious  and  placed  on  his 
right  side,  I  thrust  a  bistoury  into  the  tumor,  over  the  situation  of  the 
gluteal  artery,  and  introduced  my  finger  so  as  to  prevent  the  blood 
from  flowing  except  by  occasional  gushes,  which  showed  what  would 
have  been  the  effect  of  neglecting  this  precaution,  while  I  searched  for 
the  vessel.  Finding  it  impossible  to  accomplish  the  object  in  this 
way,  I  enlarged  the  wound  sufficiently  for  the  introduction  of  my 
fingers  h\  succession,  until  the  whole  hand  was  admitted  into  the 
cavity,  of  which  the  orifice  was  still  so  small  as  to  embrace  the  wrist 
with  a  tightness  that  prevented  any  continuous  hajmorrhage.  Being 
now  able  to  explore  the  state  of  things  satisfactorily,  I  found  that  there 
was  a  large  mass  of  dense  fibrinous  coagulum  firmly  impacted  into 
the  sciatic  notch,  and,  not  without  using  considerable  force,  succeeded 
in  disengaging  the  whole  of  this  obstacle  to  reaching  the  artery.  ,  .  . 
The  gentleman  who  assisted  me  being  prepared  for  the  next  step  of 
the  process,  I  ran  my  knife  rapidly  through  the  whole  extent  of  the 
tumor,  turned  out  all  that  was  within  it,  and  had  the  bleeding  orifice 
instantly  under  sulyection  by  the  pressure  of  a  finger.  Nothing  then 
remained  but  to  pass  a  double  thread  under  the  vessel  and  to  tie  it  on 
both  sides  of  the  aperture."  The  case  did  perfectly  well*  (Obs.  in 
Clin.  Stirg.,  p.  169). 

If,  in  the  case  of  a  stab,  the  haemorrhage  continue  after  the  ligature 

*  Nowadays  the  application  of  a  Lister's  tourniquet  to  the  abdominal  aorta  wonld 
facilitate  matters.  Another  successful  case  is  recorded  by  Mr.  J.  Bell  {Prin.  of  Surg., 
vol.  i.  p.  1801). 


LIGATURE   OF    SCIATIC    ARTERY    AND    ABDOMINAL    AORTA.  555 

has  been  applied  with  the  above  precautions,  and  the  gluteal  has 
evidently  been  punctured  within  the  pelvis,  the  internal  iliac  must  be 
tied  after  the  wound  in  the  buttock  has  been  firmly  plugged  with  dry 
gauze  or  boric  lint  and  iodoform. 

LIGATURE  OF  THE  SCIATIC  ARTERY. 

Indications. — Stab.  This  operation  is  so  very  rarely  required 
that  it  may  be  very  briefly  described  here. 

Surgical  Anatomy. — The  sciatin  artery  emerges,  together  with 
the  sciatic  nerve  and  tlie  pudic  artery,  from  the  lower  part  of  the 
great  sacro-sciatic  notch  below  the  pyriformis. 

Guide  and  Line. — The  limb  being  rotated  inwards,  a  line  is  drawn 
from  the  posterior  superior  spine  to  the  ischial  tuberosity.  The  exit 
of  the  sciatic  and  pudic  arteries  corresjionds  to  the  junction  of  the 
middle  and  lower  thirds  of  this  line. 

Operation. — The  sciatic  artery  ma}^  be  found  by  one  of  two 
incisions,  (a)  by  a  horizontal  one,  about  5  inches  long,  made  about  H 
inch  below  that  for  the  gluteal  artery,  and,  like  that,  j^arallel  with  the 
fibres  of  the  gluteus  maximus.  (b)  B}'-  one  made  vertically  in  the 
above  given  line.  The  deeper  guides  will,  be  the  margins  of  the 
notches,  or  the  great  sciatic  nerve. 

LIGATURE  OF  THE  ABDOMINAL  AORTA. 

Indications. — As  this  most  rare  operation  has  been  fatal  in  every 
one  of  the  cases  in  which  it  has  been  performed  (some  nine  or  ten),^ 
its  justifiability  has  naturally  been  called  in  question.  On  the  one 
hand,  the  desperate  condition  of  the  patients,  the  large  amount  of  dis- 
ease probably  present  in  their  arteries,  hearts,  etc.,  the  large  and  rapid 
blood  current,  the  disturbance  of  very  vital  parts,  and  the  risk  of  peri- 
tonitis, all  combine  to  render  the  probability  of  succesis  extremely 
small.  On  the  other  hand,  recent  improvements  in  surgery,  the  in- 
troduction of  better  ligatures,  the  fact  that  in  these  cases  life  must 
speedily  end  if  nothing  is  done,  and,  perhaps,  the  fact  that  many  of 
the  large  operations  of  surgery  have  been  unsuccessful  at  first,  will 
justify  surgeons  in  again  making  trial  of  this  forlorn  hope,  if  they  feel 
certain  that  otherwise  the  case  is  quite  hoi3eless. 

The  cases  have  mostly  been  those  of  iliac  and  inguinal  aneurism, 
in  which  other  arteries  have  been  tied  without  success.  To  justify 
the  epithet  above  given  of  '"  desperate,"  the  first  case,  the  well-known 
one  of  Sir  A.  Cooper  (in  1817),t  may  be  alluded  to.    Here  the  patient 

*  In  Erichsen's  Surgery  (vol.  ii.  p.  237)  seven  cases  are  given,  but  this  list  does  not 
contain  either  Dr.  P.  H.  Watson's  case  nor  the  two  of  Czerny,  though  one  of  these  is 
mentioned  later. 

f  Prill,  and  Fract.  of  Surg,  (edited  by  Dr.  Lee),  vol.  i.  p.  228. 


556  OPERATIONS  ON  THE  ABDOMEN. 

had  long  suffered  from  an  aneurism  affecting  the  external  and  com- 
mon iliac  arteries,  leading  to  sloughing  of  the  skin  and  hioniorrhage. 
Sir  Astley  liaving  failed  in  an  attempt  to  perform  the  old  operation, 
owing  to  tlie  artery  lying  so  deeply,  gave  the  patient  "  the  only  hope 
of  safety  "  which  remained,  hy  tying  the  aorta.  As  life  was  here  pro- 
longed for  forty  hours,  and  as  in  Monteiro's  case  death  did  not  take 
place  till  the  tenth  day,  proof  is  given  of  the  restoration  of  the  collat- 
eral circulation.  As  bearing  on  this  point  the  words  of  Sir  A.  Cooper 
are  of  great  interest :  "  I  knew  that  the  aorta  had  been  obliterated 
within  the  chest,  and  that  the  circulation  had  been  carried  on  by  the 
intercostal  arteries  going  from  above  to  just  below  the  spot  where  the 
aorta  was  obliterated  ;  the  insides  of  the  ribs  are  covered  with  numer- 
ous vessels.  A  gentleman  of  Dublin  had  a  preparation  in  which  the 
aorta  had  been  obliterated  in  the  abdomen,  and  in  this  case  the  circu- 
lation w^as  carried  on  by  the  lumbar  arteries  going  from  above  to  below 
the  part  where  the  vessel  was  obliterated."* 

In  addition  to  the  above  cases,  in  which  the  aorta  has  been  tied  in 
cases  of  aneurism,  it  has  been  tied  once  for  haemorrhage  after  a  gun- 
shot injury  of  the  upper  part  of  the  thigh  by  Czerny  of  Heidelberg. 
Hsemorrhage  continuing,  the  common  femoral  was  tied,  together  with 
the  superficial  femoral  below  the  profunda.  Bleeding  taking  place 
ao"ain  in  six  days,  the  common  iliac  was  tied.  The  haemorrhage  still 
persisting,  it  was  thought  that  the  external  iliac  only  had  been  tied, 
and  a  ligature  was  next  placed,  l)y  mistake,  upon  the  aorta.  The 
patient  lived  twenty-six  hours.  The  same  surgeon  during  a  nephrec- 
tomy for  a. soft  malignant  growth  of  the  kidney  met  with  such  uncon- 
trollable haemorrhage  as  to  compel  him  to  tie  the  aorta,  the  patient 
dying  soon  after. 

Surgical  Anatomy, — The  lowest  part  of  the  aorta — viz.,  that 
between  the  bifurcation  and  the  origin  of  the  inferior  mesenteric — is 
that  which  should  be  chosen.f 

The  vessel  may  have  in  front  of  it  the  omentum,  duodenum,  mesen- 
tery, small  intestines,  and  more  closely,  the  aortic  plexus  of  the 
sympathetic,  and  a  layer  of  fascia  of  varying  strength.     To  the  right 

*  In  comparing  these  instances  of  the  restoration  of  the  circulation,  the  one  by  dis- 
ease and  tlie  other  after  the  surgeon's  litrature,  tlie  importance  of  tlie  slow  and  gradual 
process  in  the  one  case  will  not  be  lost  sight  of.  Mr.  Barwell  {Intern.  Encycl.  of  Surg., 
vol.  iii  p.  481 )  alludes  to  the  experiments  of  Pi rogoff  (Waller  and  von  Griife's  Journ., 
Bd.  xxvii.  s.  122)  and  a  paper  by  Kast  {Zeit.f.  Chir.,  Bd.  xii.  s.  405)  to  show  that  the 
collateral  circulation  is  established.  Sir  A.  Cooper  {loc  supra  cit.)  used  to  show  in  his 
lectures  an  injected  specimen  from  a  dog  wliich  survived  the  operation.  Beyond  this 
fact,  however,  no  comparison  can  be  made  between  the  chance  of  survival  of  healthy 
animals  and  that  of  patients  reduced  to  such  straits  as  to  call  for  this  operation. 

f  This  interval  varies  in  length  from  J  inch  to  2  inches. 


LIGATURE    OF   THE    ABDOMINAL    AORTA.  557 

side  lies  the  vena  cava,  and  behind  it  are  the  left  lumbar  veins.  The 
bifurcation  is  usually  situated  a  little  to  the  left  side  of  the  umbilicus 
and  about  f  inch  below  it. 

Operation. — This  may  be  performed  (A)  through,  or  (B)  behind, 
the  jDeritoneum.  In  deciding  which  method  to  make  use  of,  the 
surgeon  will  be  influenced  by  the  extent  to  which  he  is  convinced 
that  the  improvements  of  modern  surgery  have  lessened  the  risks  of 
interfering  with  the  contents  of  the  abdomen,  and  of  dividing  the  two 
layers  of  peritoneum  ;  while  the  other  course  is  open  when  the 
amount  of  distension  of  the  intestines,  or  any  evidence  of  matting  of 
the  structures  of  the  abdominal  wall  (dating  to  any  inflammation 
about  the  aneurism,  or  to  the  use  of  pressure),  would  probably  inter- 
fere with  stripping  up  the  peritoneum. 

A.  Through  the  Peritoneum.— The  bowels  having  been  emptied  as 
much  as  possible,  the  skin  cleansed,  the  shoulders  raised,  and  the 
knees  slightly  flexed,  the  surgeon  makes  an  incision  at  least  4  inches 
long,  in  the  middle  line,  with  its  centre  opposite  to  the  umbihcus, 
but  curving  a  little  to  the  left  here,  so  as  to  avoid  the  round  ligament 
of  the  liver  and  the  urachus.  The  linea  alba  being  found  and  divided, 
the  fascia  transversalis  slit  up,  all  haemorrhage  must  be  arrested  before 
opening  the  peritoneum.^  When  this  structure  has  been  opened  to 
the  whole  extent  of  the  wound  retractors  are  inserted,  and  the  small 
intestine  and  mesentery  drawn  partly  upwards  and  partly  to  the 
sides,  carbolized  sponges  being  packed  around,  if  needful,  to  keep 
the  above  structures  out  of  the  way.  The  pulsation  of  the  vessel  is 
now  felt  for,  and  the  deeper  layer  of  peritoneum  carefully  scratched 
through.  Care  should  be  taken  to  disturb  as  little  as  possible  the 
aortic  plexus  f  during  this  step,  and  in  passing  the  needle,  which 
should  be  carried  from  right  to  left. 

The  ligature  used  should  be  one  of  the  flat  tape-like  ones,  of  kangaroo- 
tendon  or  ox-aorta.  The  ])assage  of  the  needle  may  be  attended  with 
much  difficulty, J  not  only  from  the  depth  of  the  vessel,  and  from  the 

*  In  Mr.  James's  case  {Med.  Chir.  Trans.,  vol.  xvi.  p.  10)  a  large  quantity  of  blood 
was  found  in  the  abdominal  cavity.  This  luul  come  either  from  a  vessel  in  the  pari- 
etes,  or  from  one  wounded  in  tiie  mesentery. 

t  Sir  A.  Cooper  {loc.  supra  cit.)  believed  that  his  experiments  on  dogs  proved  that 
inclusion  of  this  plexus,  and  not  the  interruption  of  the  circulation,  was  the  cause  of 
the  paralysis  which  followed  the  experiment.  In  Mr.  James's  case,  when  tlie  ligature 
was  tightened,  the  patient  complained  of  "deadness  in  the  lower  extremities."  This 
was  soon  followed  by  agonizing  pain  in  the  same  parts,  only  relieved  by  death  about 
three  hours  after  the  operation. 

X  Thus,  in  Mr.  James's  case  tiie  aneurism-needle  broke  at  its  handle,  the  surgeon 
having  "little  anticipated  occasion  for  so  much  force."  In  one  case  the  sac  gave  way 
during  the  operation. 


558  OPERATIONS  ON  THE  ABDOMEN. 

presence  of  intestines  if  distended  and  allowed  to  protrude  into  the 
wound,  but  also  from  the  denseness  of  the  cellular  tissue  surrounding 
the  artery. 

B.  Behind  the  Peritoneum. — This  method  should  certainly  be  tried 
in  any  future  cases.  The  chief  objection  is  the  great  depth  at  which 
the  artery  is  reached,  but  it  is  well  worthy  of  notice  that  in  Monteiro's 
case,  which  survived  ten  days,  this  method  was  made  use  of. 

The  operation  is  performed  on  much  the  same  lines  as  those  already 
given  for  ligature  of  the  common  iliac  (p.  546).  The  incision  should 
be  as  free  as  possible,  from  the  top  of  the  tenth  rib,  curving  somewhat 
forward  to  the  anterior  superior  spine.*  The  muscles  and  trans- 
versalis  fascia  being  cut  through,  the  peritoneum  is  stripped  up  and 
turned  inwards,  several  large  retractors  placed  in  the  wound,  and  the 
rib  dragged  up  and  outwards.  The  common  iliac  being  found  this 
vessel  is  traced  up  into  the  aorta  (Fig.  94). 


CHAPTER  II. 


OPERATIONS  ON  HERNIA.t  — OPERATIONS  FOR 
STRANGULATED  HERNIA-RADICAL  CURE  OF 
HERNIA. 

OPERATION  FOR  STRANGULATED  HERNIA. 

Chief  Indications  for  Operation  and  Points  to  bear  in  Mind. 

— While  this  is  not  the  place  for  going  into  the  above  fully,  a  few 
practical  remarks  on  those  indications  usually  given  may  be  helpful 
to  some  of  my  readers. 

i.  A  lump  in  one  of  the  openings  more  or  less  hard,  tense  and 
tender,  partly  or  completely  irreducible,  and  with  doubtful  or  no 
impulse. 

a.  The  swelling  may  be  small  and  deep-seated,  as  in  a  small 
bubonocele  near  the  internal  abdominal  ring,  or  a  tiny  femoral  in  a 
fat  patient. 

b.  Two  hernia?  may  be  present,  both  irreducible.  The  surgeon 
should  operate  on  the  one  which  is  the  more  tense  and  has  the  least 
impulse,  and  the  one  which  has  most  recently  descended.     If  this  fail 

*  If  necessary,  a  horizontal  one  might  be  added,  at  right  angles  to  the  first,  but  the 
rectus  and  the  deep  epigastric  should  on  no  account  be  interfered  with. 

f  The  difierent  forms  of  liernia,  those  which  present  on  the  thigh  as  well  as  the 
inguinal  and  umbilical  varieties,  will  be  considered  here  for  the  sake  of  convenience, 
and  because  they  are  all  abdominal  in  origin. 


STRANGULATED    FEMORAL    HERNIA.  559 

to  give  relief,  either  the  opposite  swelling  must  be  explored  or  abdom- 
inal section  performed  in  the  middle  line.  This  step  will  probably 
allow  of  the  opposite  hernia  being  reduced  from  within,  and  at  the 
same  time  of  any  other  possible  seats  of  strangulation  being  exposed — 
viz.,  the  inner  aspects  of  the  deeper  rings. 

c.  "With  regard  to  the  impulse,  it  is  worth  while  to  observe  carefully 
the  point  where  this  ceases.  This  point,  probably,  is  over  the  site  of 
stricture,  and  should  be  about  the  centre  of  the  incision. 

d.  Sir  J.  Paget  (Clin.  Led.,  p.  108)  thus  writes  of  the  hardness  of  a 
hernia :  "  In  large  hernite  the  hardness  may  chiefly  be  felt  at  and 
near  the  neck  and  mouth  of  the  sac,  especially  in  inguinal  hernia, 
and  you  must  take  care  not  to  be  deceived  by  a  sac  which  is  soft  and 
flaccid  everywhere  except  at  its  mouth,  for  there  may  be  strangulated 
intestine  in  the  mouth  of  the  sac  though  the  rest  contain  only  soft 
omentum  or  fluid  not  sufficient  to  distend  it ;  nay,  you  must  not  let 
even  a  wholly  soft  condition  of  the  hernia,  or  an  open  external  ring, 
weigh  down  against  the  well-marked  symptoms  of  strangulation,  for 
the  piece  of  intestine  at  the  mouth  of  the  sac  may  be  too  small  to 
give  a  sensation  of  hardness,  or  the  whole  hernia  may  be  omental." 

ii.  Constipation  becoming  absolute,  even  as  to  the  passage  of  flatus. 
It  is  well  known  that,  occasionally,  small  scybalous  motions  may  be 
forced  out  fey  the  straining  of  a  patient  with  a  strangulated  hernia 
anxious  to  get  his  bowels  to  act.  It  must  be  also  remembered  here, 
and  in  intestinal  obstruction  generally,  that  the  bubbling  away  of  an 
enema  may  stimulate  the  passage  of  flatus. 

iii.  Vomiting.*  Especially  if  (a)  this  is  changing  from  the  early 
rejection  of  stomach  contents  or  bile  to  feculent  fluid ;  (6)  even  if  it  is 
repeated  only  at  long  intervals,  and  all  other  signs  are  absent  or  little 
marked ;  (c)  it  must  be  remembered  that  vomiting  may  be  stopped 
by  drugs,  strangulation  persisting. 

iv.  Tympanites  and  other  evidence  of  peritonitis. 

These  will  not,  of  course,  debar  the  surgeon  from  operating,  but 
they  will  lead  him  to  warn  the  friends  that  relief  will  probably  come 
too  late. 

STRANGULATED  FEMORAL  HERNIA  (Fig.  96). 

Operation. — The  parts  being  shaved  and  cleansed  with  soap  and 
carbolic-acid  lotion  (1  in  60)  or  perchloride  of  mercury  lotion  (1  in 
1000),  a  little  iodoform  rubbed  in  around  the  genitals,  the  limbs 
being  kept  warm  with  blankets  and  a  hot  bottle  or  two,  if  the  patient's 

*  Sir  J.  Paget  {loc.  supra  cit.,  p.  112)  says:  "  If  I  were  asked  wliich  of  the  signs  of 
stranguhitiou  I  would  most  rely  on  as  couimaiiding  the  operation,  I  should  certainly 
say  the  vomiting." 


660  OPERATIONS  ON  THE  ABDOMEN. 

vitality  is  low,  and  the  knee  flexed  slightly  over  a  pillow,  an  incision 
H  to  2  inches  long  is  made  vertically  on  the  inner  side  of  the  swell- 
ing* Some  small  branches  of  the  superficial  external  pudic  occa- 
sionally require  torsion  or  ligature.  The  cribriform  fascia  and  the  fascia 
propria  (femoral  sheath  and  septum  crurale) 
■  are  next  divided  in  the  same  vertical  line  with 

or  without  a  director,  according  to  their  thick- 
ness and  the  experience  of  the  operator,  all  the 
incisions  made  going  quite  up  to  and  above  the 
top  of  the  swelling,  so  as  to  lie  over  the  seat  of 
strangulation,  usually  Gimbernat's  ligament. 
In  the  operation  without  opening  the  sac,t 
the  site  of  stricture  must  next  be  found.  The 
varieties  here  are  best  given  in  Sir  James 
Paget's  words :  J  "  In  some  instances,  as  you 
trace  up  the  neck  of  the  sac,  you  find  it  tightly 
banded  across  by  the  layer  of  fibrous  tissue  called  Hey's  ligament — 
a  layer  traceable  as  a  falciform  edge  of  the  fiiscia  lata,  where  that 
fascia,  bounding  the  upper  part  of  the  saphenous  opening,  is  con- 
nected with  the  crural  arch,  and  is  thence  continued  to  Gimbernat's 
ligament.  Sometimes  a  fair  division  of  this  layer  of  fibres  up  to  the 
edge  of  the  crural  arch  is  sufficient  to  render  the  hernia  reducible.  . ' .  .  . 
But  in  more  cases  this  is  not  sufficient,  and  you  may  feel  the  stricture 
formed  by  bands  of  fibres  which  encircle  the  neck  of  the  sac,  and 
which  must  be  divided,  band  by  band  and  layer  by  layer,  till  none 
can  be  felt.  These  fibres  are  part  of  the  deep  crural  arch.  Very  rarely, 
however,  even  the  division  of  these  is  not  suflScient,  for  the  stricture 
is  formed  by  thickening  of  the  mouth  of  the  sac  itself.  This  con- 
dition, which  is  a  common  cause  of  stricture  in  inguinal  hernia,  is 
very  rare  in  femoral ;  but  it  certainly  does  occur,  and  in  any  case  well 
suited  for  the  operation  without  opening  the  sac,  you  may  try  to  thin 
the  mouth  of  the  sac  without  opening  it,  and  thus  to  make  it  exten- 


*  Tliis  incision  is  iisnnlly  made  in  the  ordinary  way.  A  somewhat  quicker  method 
is  by  incising  or  transfixing  a  fold  pinched  up  at  a  right  an^le  to  the  long  axis  of  the 
swelling,  and  held  by  the  fingers  of  the  surgeon  and  an  assistant.  Before  beginning 
the  operation,  the  surgeon  should  always  examine  into  the  probable  amount  of  fat,  and 
thickness  or  thinness  of  the  hernial  coverings.  In  tiie  case  of  a  large  hernia  turning 
outwards  and  upwards,  it  may  be  well,  at  a  later  stage  of  the  operation,  if  any  addi- 
tional exploration  is  required  of  doubtful  contents,  to  convert  the  first  incision 
into  a  — ^ 

t  Cases  best  suited  for  this  plan  are  those  where  the  strangulation  has  been  short ; 
its  symptoms  not  very  severe— e.,*?.,  the  vomiting  only  bilious ;  where  the  hernia  is 
small  in  size  and  without  mixed  contents;  where  the  patient  is  in  good  condition,  and 
any  previous  taxis  has  been  gentle  and  brief. 

X  Loc.  supra  cit.,  p.  132. 


STRANGULATED    FEMORAL    HERNIA.  561 

sible  enough  for  the  return  of  its  contents.  You  may  try  this,  but  the 
chances  of  success  are  small.  You  are  much  more  likely  to  cut  into 
the  sac  at  some  thin  place,  and  when  you  have  done  this  you  had 
better  enlarge  the  opening  and  divide  the  stricture  from  within."* 

Operation  by  opening  the  Sac. — In  this  and  in  the  former  case 
much  difficulty  is  occasionally  met  with  in  deciding  as  to  whether 
the  sac  is  reached  or  no.  Tlie  causes  of  difficulty  here  are  mainly — 
(1)  An  altered  condition  of  the  soft  parts  from  the  pressure  of  a  truss, 
or  from  long  strangulation ;  (2)  from  meeting  with  fluid  outside  the 
sac;  (3)  from  the  extreme  thinness  of  the  patient,  which  leads  to  the 
sac  being  reached  unexpectedly  ;  (4)  from  the  opposite  condition, 
much  fat  being  met  with  in  several  of  the  deeper  layers,  making  it 
uncertain  which  is  the  extra-peritoneal  layer,  the  fat  in  these  oases 
being  often  soft,  and  readily  breaking  down  under  examination ; 
(5)  an  apparently  puzzling  number  of  layers  — this  condition  is 
usually  due  to  "  hair-splitting  "  over-carefulness  on  the  part  of  the 
operator;  at  other  times  it  is  brought  about  by  a  much  thickened 
fascia  propria f  separated  into  imperfect  layers  by  its  softened  con- 
dition or  inflammatory  matting ;  (6)  by  the  absence  of  a  sac.  J 

Aids  in  recognizing  tJie  Sac  in  Cases  of  Diffic  Ity. — -Several  of  those 
ordinarily  given  § — e.g.,  "  its  rounded  and  tense  appearance,  its  fila- 
mentous character,  and  the  aborescent  appearance  of  vessels  on  its 
surface  " — are,  I  think,  quite  fallacious.  So,  too,  with  regard  to  the 
escape  of  fluid  from  the  sac,  for  this  is  often  dry  in  femoral  hernise, 
and  occasionally  fluid  is  met  with  before  the  sac  is  reached.  A.  smooth 
lining  characteristic  of  its  inner  surface  is  more  reliable,  but  the  inner 
surface  of  the  fascia  propria  is  sometimes  remarkably  smooth,     Two 

*  In  trying  to  divide  points  of  stricture  outside  the  sao,  attention  should  be  paid  to 
the  following;  (1)  First  reaching  the  sac  itself,  if  possible,  by  a  careful  division  of 
all  the  overlying  structures  in  the  vertical  incision  carried  well  npwards;  (2)  By 
carefully  drawing  down  the  sac,  so  as  to  expose  any  fibres  constricting  its  neek;  (3) 
By  gently  insinuating  the  point  of  the  director  under  any  bands  met  with, 

f  The  fascia  propria,  thougli  sometimes  of  wafer  thinness,  may  be  much  thickened 
and  difficult  of  recognition.  In  Mr.  Erichsen's  words  (Surc/ery,  yol.  ii.  p.  821),  "  Jt 
not  unfrequently  happens  that,  after  tiie  superficial  f;iscia  has  been  divided,  an  oval, 
smooth  and  firm  body  is  exposed,  which  at  first  looks  like  the  hernial  sac  or  a  lump  of 
omentum.  This  is  in  reality  the  fascia  propria,  thickened  by  the  long-continued 
pressure  of  the  truss,  and  congested  perhaps  by  the  attempts  at  reduction  ;  and  in  the 
midst  of  it  the  sac  will  at  length  be  found,  after  the  dissection  has  been  carried  through 
several  layers  of  this  tissue, 

X  A  sac  is  said  to  be  absent  in  some  cases  of  hernia  of  the  caecum,  and  where  the 
patient  has  been  operated  on  before.  This,  however,  was  not  the  case  in  three  hernias 
containing  the  caecum,  and  in  two  which  had  been  operated  on  before,  which  came 
under  my  care. 

§  Erichsen,  loc.  supra  cit, 

S6 


562  OPERATIONS  ON  THE  ABDOMEN. 

points  remain  which  will  help  to  solve  the  doubt — (a)  To  draw  gently- 
down  the  doubtful  structure,  whether  sac  or  boAvel,  and  to  examine 
whether  it  is  continuous  above  and  below  with  the  structures  of  the 
abdomen  and  thigh,  like  the  other  coverings  of  the  hernia,  or  whether 
it  has  a  distinct  neck  to  be  traced  into  the  abdominal  cavity  ;  (b)  To 
see  if  the  point  of  a  Key's  director  can  be  insinuated  along  this  last 
doubtful  layer  into,  and  moved  within,  the  peritoneal  cavity  or  no. 
In  a  very  few  cases  the  surgeon,  if  still  in  doubt,  incises  carefully  the 
suspected  layer,  and  tries  if  he  can  pass  in  a  probe  and  move  it  from 
side  to  side ;  if  this  can  be  done,  he  is  still  outside  the  bowel,  not 
between  the  peritoneal  and  muscular  coats  of  intestine. 

The  sac  being  carefully  nicked  with  the  scalpel-blade  held  horizon- 
tally at  a  spot  where  it  can  best  be  pinched  up  with  dissecting-forceps, 
a  matter  of  much  difficulty  at  times  owing  to  its  tenseness,  is  slit  up 
on  a  director,  and  its  contents  examined.  If  omentum  first  present 
itself,  this  is  drawn  to  one  side  and  unravelled,  and  intestine  sought 
for.  This  usually  takes  the  form  of  a  small,  very  tense  knuckle,  of 
varying  color  and  condition.  If  it  will  facilitate  the  manipulations 
needful  for  reduction,  the  omentum  may  be  first  dealt  with.  (1)  If  this 
be  voluminous  and  altered  in  structure,  it  should  be  tied  bit  by  bit 
with  carbolized-silk  ligatures,  and  then  cut  away,  the  scissors  being 
applied  so  close  to  the  ligatures  as  to  leave  holding-room,  but  no  excess 
to  mortify  or  slough.  After  the  return  of  the  intestine,  the  omentum 
is  also  replaced  within  the  al)domen.  (2)  If  the  omentum  is  small  in 
amount  and  recently  descended,  it  may  be  merely  returned.  (3)  In  a 
few  rare  cases  when  the  omentum  is  intimately  adherent  to  tlie  sac,  and 
the  patient's  condition  does  not  admit  of  delay,  the  omentum  may  be 
left  in  situ.  As,  however,  this  course  very  much  interferes  with  the 
satisfactory  w^earing  of  a  truss,  and  as  it  is  likely  to  lead  to  a  fresh 
descent  of  bowel,  it  should  never,  if  possible,  be  followed. 

Eecluction  of  the  Intestine. — As  soon  as  this  is  exposed,  the  surgeon 
examines  with  the  little  finger-nail,  or  a  Key's  director,  the  tightness 
of  Gimbernat's  ligament.  In  a  few  cases  reduction  may  be  at  once 
eff'ected  by  gentle  pressure  backwards  on  the  bowel  with  the  tip  of  the 
little  finger.  But  in  the  large  majority  the  above  site  of  structure  will 
need  division,  a  point  requiring  much  carefulness  for  fear  of  injuring 
the  intestine  or  important  surrounding  structures.  If  the  degree  of 
tightness  of  the  parts  admit  of  it,  there  is  no  director  equally  safe  and 
satisfactory  as  the  index  or  little  finger  of  the  left  hand  passed  up  to 
the  stricture,  and  the  nail-tip  insinuated  beneath  this,  the  hernia-knife 
being  introduced  along  the  pulp  of  the  finger  (Fig.  97).  But  there  is 
rarely  room  for  this,  and  a  Key's  director -^^  must  usually  take  the  place 

*  This  director  is  broad,  s^o  as  to  prevent  any  intestine  curling  over  and  reaching 
the  knife;  bhmt-pointed,  so  as  not  to  damage  the  contents  of  the  peritoneal  cavity; 


STRANGULATED  FEMORAL  HERNIA. 


56; 


of  the  finger.  The  tip  of  this  instrument  being  insinuated  into  the 
peritoneal  cavity  just  under  Gimbernat's  ligament,  the  hernia-knife* 
is  introduced  obliquely  or  flat-wise  upon  it,  its  end  slipped  under  and 
beyond  the  ligament,  its  edge  turned  towards  the  constricting  fibres, 
and  a  few  of  these  cut  through  in  an  upward  and  inward  direction  by 

Fig.  97. t 


(Fergusson.) 

a  gentle  movement  of  the  wrist.  In  doing  this  it  is  well  for  the  sur- 
geon to  draw  down  the  edges  of  the  cut  sac  close  to  its  neck,  and  to 
ask  an  assistant  to  hold  these,  thus  facilitating  the  passage  of  the  di- 
rector and  the  knife  by  preventing  the  sac  falling  into  folds  before 
them.  Occasionally  also  a  knuckle  of  intestine  persistently  coils 
over  the  edge  of  the  director.  This  is  best  met  by  patience,  by 
drawing  it  out  of  the  way  by  the  carbolized  finger-tip  of  an  assistant, 
or  by  pressing  it  down  with  the  handle  of  a  pair  of  forceps. 

The  direction  and  the  extent  to  which  the  stricture  must  be  cut  are 
matters  of  mucli  importance.  The  upward  and  inward  line  is  the 
only  path  of  safety.  Directly  outwards  lies  the  femoral  vein  ;  by  cut- 
ting upwards,  the  spermatic  cord,  and,  if  upwards  and  outwards,  the 
epigastric  artery,  would  be  endangered ;  behind  are  the  peritoneum 
and  pubes.  The  incision  upwards  and  inwards  must  be  of  the  nature 
of  a  nick;  otherwise,  owing  to  the  imperfect  healing  of  this  fibrous 
stricture,  the  ring  will  be  left  large  and  gaping,  thus  facilitating  the 
re-descent  of  the  hernia,  and  producing  much  difficulty  in  fitting  on 
trusses,  and  causing  certain  discomfort  and  probable  peril  to  the  pa- 
tient, especially  if  she  belong  to  the  poorer,  hospital  class. 

Gimbernat's  ligament  having  been  carefully  and  sufficiently  nicked, 
the  bowel  is  replaced  either  by  gentle  squeezing  between  the  finger  and 

finally,  its  groove  does  not  run  quite  up  to  the  end,  so  that  the  knife-point  shall  be 
stopped  before  it  comes  in  contact  with  important  parts. 

*  A  curved  one  will  be  found  most  useful.  The  cutting-blade  is  usually  too  broad 
and  the  tip  too  massive.  On  the  other  hand,  a  worn-down  blade  has  been  known  to 
break  while  dividing  a  tense  Gimbernat's  ligament. 

t  The  cutting-blade  of  the  knife  shown  here  is  needlessly  long  and  unguarded. 


564  OPERATIONS  ON  THE  ABDOMEN. 

thumb,  so  as  to  enij^ty  it  of  its  contents,  or  with  the  pressure  of  the 
little  finger;  the  sac  should  now  be  kept  stretched  wdth  forceps  so  that 
no  folds  interfere  with  the  return  of  the  bowel.  If  pressure  on  the  part 
of  the  intestine  fail,  it  must  be  tried  at  another  i»oint.  After  the  re- 
duction of  the  intestine  the  tip  of  the  little  finger  should  be  introduced 
through  the  crural  canal  into  the  peritoneal  cavity  to  see  that  the  gut 
is  absolutely  safe ;  a  little  iodoform  is  then  dusted  on  to  the  stumps  of 
omentum,  and  these  too  returned,  if  this  has  not  been  done. 

If  the  patient's  condition  admit  of  it,  if  the  hernia  is  not  of  a  very 
long  standing,  and  if  the  surrounding  parts  are  healthy,  the  sac  should 
next  be  taken  away  by  carefully  separating  it  wdth  the  point  of  a  di- 
rector from  its  attachments.  Its  neck  is  then  ligatured  with  chromic 
gut  or  carbolized  silk  *  as  high  up  as  possible,  and  the  rest  cut  away 
i  inch  below  this  point.  If  the  surgeon  is  at  all  doubtful  about  the 
safe  ligature  of  any  stump  of  omentum,  he  should  keep  this  down  and 
transfix  it  and  the  neck  of  the  sac  with  a  double  chromic-gut  ligature, 
the  ends  of  which  are  afterwards  cut  short.  Sufficient  drainage  is  now 
provided  by  a  small  tube  or  a  bundle  of  horsehair,  and  the  superficial 
wound  closed.  The  dressings  must  be  applied  with  sufficient  care  to 
keep  the  wound  secured  from  obviously  close  sources  of  contamination. 
It  is  well  to  place  a  separate  pad  of  carbolized  tow  or  salycylic  wool 
over  the  anus  and  genitals,  and  to  draw  the  water  off  before  the  patient 
leaves  the  table.  The  thigh  should  not  be  kept  too  much  flexed,  other- 
wise the  escape  of  discharge  from  the  drainage-tube  will  be  interfered 
with. 

The  account  of  an  ordinary  operation  having  been  given,  it  remains 
to  consider  certain  complications.     These  are  chiefly : 

1.  Adhesions  of  Bowel  to  the  Sac  or  Omentum. — The  treatment  of 
this  uncommon  complication  must  vary  with  (a)  the  character  and 
position  of  the  adhesions,  (i5)  the  condition  of  the  intestine,  and  (y)  the 
state  of  the  patient.  Owing  to  the  difficulty  of  fitting  on  a  truss  if  any 
of  the  hernia  is  left  unreduced,  every  attempt  should  be  made  to  free 
the  contents  by  separating  the  adhesions  Avith  the  point  of  a  steel  di- 
rector, the  finger-nail,  or  a  blunt-pointed  bistoury.  When  near  the 
neck  they  must  always  be  divided,  sufficiently  nicked,  or  stretched. 
No  intestine  and  omentum  if  still  adherent  to  each  other  should  ever 
be  returned.  A  few^  cases  remain  in  wdiich  adhesions  sliould  be  left 
alone.  When  gangrene  is  threatening,  their  presence,  especially  about 
the  neck  of  the  sac,  is  the  chief  safeguard  against  extravasation  into  the 
peritoneal  cavity.  In  some  cases  of  large  hernia,  if  the  patient  is  much 
collapsed,  as  long  as  any  recently  descended  loop  is  returned  any  long- 
aclherent  intestine  may  be  left.     And  in  other  cases  of  collapse  from 

*  See  foot-note,  p.  404. 


8TRANGULATED    FEMORAL    HERXIA.  565 

delay  of  the  operation,  where  there  is  much  difficulty  in  returning  a 
loop  of  intestine,  especially  if  this  is  not  in  good  condition,  it  may  be 
left,  after  the  stricture  has  been  sufficiently  divided. 

2.  Tightly  constricted  or  Gangrenous  Intestine. — In  spite  of  all  that 
has  been  taught  about  the  importance  of  early  operations,  cases  do 
still  occur  in  which  the  advisability  of  returning  the  bowel  seems 
doubtful.  In  most  cases  of  doubt,  as  long  as  the  stricture  is  sufficiently 
divided  and  the  intestine  placed  only  just  within  the  crural  ring  (the 
wound  being  left  open  and  the  sac  not  ligatured  in  these  cases),  the 
interior  of  the  abdomen  is  the  best  place  for  the  intestine.  And  this 
is  true  of  congested  intestine,  however  deeply  loaded  with  blood  only, 
as  long  as  there  is  some  shade  of  red  present.  But  on  these  points 
nothing  will  surpass  the  advice  of  Sir  J.  Paget:*  "You  are  to  judge 
chiefly  from  the  color  and  the  tenacity.  Use  your  eyes  and  your 
fingers ;  sometimes  your  nose ;  very  seldom  your  ears,  for  what  you 
ma}^  be  told  about  time  of  strangulation,  sensations,  and  the  rest  is  as 
likely  to  mislead  you  as  to  guide  aright.  As  to  color  ....  I  am  dis- 
posed to  say  that  you  may  return  intestine  of  any  color  short  of  black, 
if  its  texture  be  good ;  if  it  feels  tense,  elastic,  well  filled  out,  and 
resilient,  not  collapsed  or  sticky ;  and  the  more  the  surface  of  the  in- 
testine shines,  and  glistens,  the  more  sure  you  may  be  of  this  rule. 
When  a  piece  of  intestine  is  thoroughly  black,  I  believe  you  had 
better  not  return  it,  unless  you  can  be  sure  that  the  blackness  is  wholly 
from  extra vasated  blood.  It  may  not  yet  be  dead,  but  it  is  not  likely 
to  recover ;  and,  even  if  it  should  not  die  after  being  returned,  there 
will  be  the  great  risk  of  its  remaining  unfit  to  propel  its  contents,  and 
helping  to  bring  on  death  by  what  appears  very  frequent — distension 
and  paralysis  of  the  canal  above  it.  But,  indeed,  utter  blackness  of 
strangulated  intestine  commonly  tells  of  gangrene  already  ;  and  of  this 
you  n)ay  be  sure  if  the  black  textures  are  lustreless,  soft,  flaccid  or 
viscid,  sticking  to  the  fingers  or  looking  villous.  Intestine  in  this  state 
should  never  be  returned.  Colors  about  which  there  can  be  as  little 
doubt,  for  signs  of  gangrene,  are  white,  gray,  and  green,  all  dull,  lus- 
treless, in  blotches  or  complete  over  the  whole  protruded  intestine. 

Then  as  to  the  texture  of  the  intestine :  it  should  be,  for  safety 

of  return,  thin- walled,  firm,  tense,  and  elastic,  preserving  its  cylindrical 
form,  smooth,  slippery,  and  glossy.  The  further  the  intestine  deviates 
from  these  characters,  the  more  it  loses  its  gloss  and  looks  villous,  the 
more  it  feels  sticky  and  is  collapsed  and  out  of  the  cylinder  form,  the 
softer  and  more  yielding,  the  more  pulpy,  or  like  wet  leather  or  soaked 
paper,  the  less  it  is  fit  for  return.  And  when  these  characters  are  com- 
bined with  such  bad  colors  as  I  have  described,  the  intestine  had 

*  Log.  supra  cit.,  p.  138. 


566  OPERATIONS  ON  THE  ABDOMEN. 

better  be  laid  open,  that  its  contents  may  escape  exteniall}'  and  do  no 
harm. 

In  other  long-standing  cases  of  femoral  hernia  the  chief  stress  of  the 
constriction  is  shown,  not  on  a  dying  loop  of  intestine,  but  in  ulcera- 
tion, partial  or  nearly  ring-like,  at  the  neck  of  the  sac,  under  the  sharp 
edge  of  Gimbernat's  ligament.  Where  this  condition,  owing  to  the 
duration  of  the  case,  is  suspected,  the  intestine  should  be  very  gently 
drawn  down,  and,  if  ulceration  is  found,  laid  open.  If  the  mischief 
is  localized  and  the  adjacent  intestine  fairly  healthy  and  not  fixed,  it 
will  be  well  to  stitch  it  to  adjacent  parts  to  prevent  it  slipping  up  into 
the  peritoneal  cavity. 

It  has  been  much  disputed  whether,  in  these  cases,  when  the 
intestine  is  unfit  to  be  returned,  it  is  safe  or  needful  to  divide  the 
stricture  in  addition  to  laying  open  the  intestine.  On  the  one  hand, 
M.  Dupuytren,  Sir  A.  Cooper,  Mr.  Key,  and  Mr.  Erichsen  have  advo- 
cated this  step  being  taken ;  on  the  other,  Mr.  Travers  and  Sir  AV. 
Lawrence  were  against  it.  The  following  words  of  a  very  brilliant 
writer*  will  probably  convince  most  that  this  step  is  not  only  injuri- 
ous, but  unneeded  :  "  The  only  result  of  this  is  that  the  protecting 
barrier  which  divides  the  still  aseptic  peritoneal  cavity  from  the  putrid 
sac,  is  broken  down,  and  putridity  spreads  upwards  into  the  abdomen 
and  kills  the  patient  by  rapid  septiccemic  poisoning.  Why  break 
down  this  valuable  wall?  If  it  is  argued  that,  unless  the  stricture  is 
divided,  the  contents  of  the  bowel  cannot  escape,  then  the  reply  is 
that  experience  proves  this  to  be  utterly  untrue.  In  a  very  short  time 
both  flatus  and  fseces  find  their  way  out.  As  every  one  knows,  the 
nipping  of  the  gut  is  not  produced  b}"  a  sudden  narrowing  of  the 

hernial  aperture,  but  l)y  a  swelling  of  the  loop  of  gut When 

the  gut  is  slit  up,  its  contents  are  set  free,  and  its  inflammatory  juices 
escape,  with  the  result  that  its  swelling  goes  down  and  room  enough 
is  soon  permitted  for  wind  and  feeces  to  pass,  more  particularly  as  the 
fseces  are  invariably  quite  liquid." 

3.  The  treatment  of  artificial  anus  is  considered  together  with  resec- 
tion of  the  intestine  infra.  It  will  suffice  here  to  say  that  in  cases 
of  hernia,  owing  to  the  condition  of  the  intestine,  the  state  of  the 
patient,  and  often  the  absence  of  needful  preparations  and  good  light, 
no  attempt  should  be  made  to  resect  the  damaged  parts  now. 

4.  Wound  of  Intestine. — This  may  be  due  to  (a)  carelessly  incising 
thin,  soft  parts ;  (b)  great  difficulty  in  making  out  sac  and  intestine 
in  a  fat  patient,  with  the  parts  matted,  especially  if  the  light  is  bad  ; 
(c)  to  the  intestine  being  allowed  to  curl  over  the  edge  of  the  director 

*  Mr.  M.  Banks,  Clinical  Notes  on  Two  Years'  Surgical  Worfc  in  the  Liverpool  Royal 
Infirmary,  p.  9o. 


STEANGULATED    FEMORAL    HERNIA.  567 

while  the  stricture  is  being  divided,  or  to  this  being  cut  with  careless 
freedom,  or,  lastly,  to  a  loop  lying  out  of  sight  just  above  the  constric- 
tion, and  to  the  hernia-knife  coming  in  contact  with  this.  Any  bub- 
bling of  flatus  or  escape  of  treces  from  the  wound  must  lead  to  a 
careful  search  for  the  opening.  When  this  is  found,  it  may  usually 
be  tied  up  around  a  pair  of  dissecting-forceps  with  carbolized  silk,  the 
ligature  not  being  tied  too  tightly,  and  the  ends  cut  short.  If  the 
opening  be  larger,  it  should  be  closed  by  Lembert's  suture  (infra, 
Figs.  106,  107).  Whichever  method  is  used,  the  injured  part  should 
be  replaced  just  Avithin  the  peritoneal  cavity,  and  in  a  severe  case  the 
sac  should  not  be  taken  away  nor  the  wound  closed.  The  patient 
should  be  kept  under  the  influence  of  opium,  and  liquids  restricted. 

5.  Wound  of  Obturator  Artery. — The  position  of  this  vessel  when 
it  rises  by  a  common  trunk  with  the  deep  epigastric  instead  of  from 
the  internal  iliac,  which  occurs  in  every  02  subjects  (Gray),  may  bear 
a  very  imi:)ortant  relation  to  the  crural  ring.  In  most  cases  when  thus 
arising  abnormally,  the  artery  descends  to  the  obturator  foramen  close 
to  the  external  iliac  vein,  and  therefore  on  the  outer  side  of  the  crural 
ring  and  out  of  harm's  way.  In  a  small  minority  of  cases,*  the  arter}- 
in  its  passage  downwards  curves  along  the  margin  of  Gimbernat's 
ligament,  and- may  now  be  easily  wounded. 

The  treatment  is  mainly  preventive — i.e.,  by  making  the  smallest 
nick  possible  that  will  be  sufficient  into  any  point  of  stricture,  such 
as  Gimbernat's  ligament,  a  point  the  importance  of  which  has  alread}^ 
been  alluded  to  (p.  563),  and  using  a  hernia-knife  that  is  not  over- 
sharp.  If  the  artery  has  probably  been  wounded,  the  following  points 
are  of  interest:  (1)  The  haemorrhage  may  not  at  once  follow  the 
wound.  It  may  not  make  its  appearance  till  the  bowel  is  all  reduced, 
or  even  until  a  c[uarter  of  an  hour  after  the  wound  has  been  stitched 
up.  In  one  case,  that  of  Dupuytren,  no  haemorrhage  occurred,  and 
the  division  of  the  artery  was  discovered  for  the  first  time  at  the 
autopsy  three  weeks  after  the  operation.  (2)  It  may  occur  when  the 
sac  has  not  been  opened.  (3)  As  is  shown  by  Dupuytren's  case,  it  is 
by  no  means  a  fatal  accident.  Very  various  means  have  served  to 
arrest  the  haemorrhage.  («)  Pressure  usually  ap})lied  by  a  pad,t  as  in 
the  cases  of  Sir  W.  Lawrence,  Mr.  Hey,  and  Mr.  Barker.]:  (,3)  Liga- 
ture of  the  vessel,  usually  the  proximal  end.     In  five  cases  given  by 

*  Sir  W.  Lawrence  considered  this  risk  to  occur  about  once  in  a  hundred  tinaes, 
estimating  the  origin  of  the  oijturator  wiili  tlie  epigastric  to  occur  once  in  live,  and  the 
descent  of  the  artery  on  the  inner  side  to  take  place  once  in  twenty  times. 

f  Or  better,  by  pledgets  of  aseptic  gauze  or  sponges  dusted  with  iodoform,  and 
secured  by  silk. 

X  Clin.  Soc.  Trans.,  vol.  xi.  p.  180.  This  paper  will  well  repay  perusal.  Most 
of  the  above  information  is  taken  from  it. 


568  OPERATIONS  ON  THE  ABDOMEN. 

Mr.  Barker,  this  was  successful  in  four ;  it  is  only  stated  in  one  that 
the  distal  end  was  also  secured.  The  ligature  has  been  applied  in 
some  cases  by  continuing  the  wound  upwards  ;  in  others  by  making 
an  incision  parallel  with  Poupart's  ligament,  as  if  for  tying  the  exter- 
nal iliac.  This  step  could  only  be  taken  when  the  patient's  condition 
was  satisfactory,  (y)  By  acupressure.  This  method  was  thus  made 
use  of  by  Mr.  Corlcy :  The  gush  of  arterial  haemorrhage  which  took 
place  the  moment  the  intestine  was  returned  was  controlled  by  pass- 
ing a  curved  needle  through  the  ring,  and  bringing  it  out  immediately 
above  Poupart's  ligament,  and  passing  a  figure-of-eight  suture  over  it. 
No  recurrence  of  haemorrhage  took  place,  but  the  patient  died  thirty 
hours  later.  At  the  autopsy  about  4  ozs.  of  clot  were  found  in  the 
sub-serous  tissue.  The  obturator  sj^ringing  from  the  epigastric,  and 
being  about  the  size  of  a  No.  3  bougie,  took  the  dangerous  course  over 
the  neck  of  the  sac.  The  cardiac  end  was  occluded  by  clot.  The 
distal  end  had  retracted  IJ  inches  from  the  cardiac,  and  was  open. 
Though  the  needle  had  controlled  the  hsemorrhage,  it  had  not  included 
the  artery.  In  two  of  Sir  W.  Lawrence's  cases  the  fainting  of  the 
patient  appears  to  have  decided  the  cessation  of  haemorrhage.  Both 
of  these  recovered.  In  the  event  of  pressure  failing,  it  might  be  worth 
while,  before  taking  other  steps,  to  try  the  application  of  a  pair  of 
Spencer  Wells's  forceps.  These  would  be  left  in  situ  for  three  or  four 
days,  and  would  favor  drainage. 

STRANGULATED  INGUINAL  HERNIA  (Figs.  98,  99). 

Operation. — In  considering  this  it  will  not  be  needful  to  go  again 
into  detail,  as  in  the  case  of  Strangulated  Femoral  Hernia  ;  the  chief 
points  of  difference  and  those  of  importance  will  be  considered  care- 
fully. 

The  i^arts  being  shaved  and  cleansed  (p.  581),  and  the  thigh  a  little 
flexed,  an  incision  22  inch  long  at  first  is  made  in  the  long  axis  of  the 
tumor,  with  its  centre  (in  an  ordinary  scrotal  case  *)  over  the  external 
abdominal  ring.  This  incision  may  be  made  either  by  pinching  up  a 
fold  and  cutting  from  Avithin  outwards,  or  by  cutting,  in  the  usual 
way,  from  without  inwards.  The  external  pudics  (both  superior  and 
inferior)  often  now  require  ligature  or  torsion.  As  the  layers  are 
divided,  the  knife  bemg  kept  strictly  in  the  same  line  throughout, 
some  arching  fibres  of  the  inter-columnar  fascia  may  be  seen  above, 
but  the  first  layer  usually  recognized  is  the  cremasteric  fascia,  often 
much  thickened.  After  this  the  transversalis  fascia,  also  often  thick- 
ened and  vascular-looking,  is  slit  up,  and  any  extra-peritoneal  fat 

*  In  a  strangulated  bubonocele  the  centre  of  the  incision  should  lie  over  the 
internal  abdominal  ring,  and  in  the  deeper  part  of  the  incision  the  deep  epigastric 
must  be  felt  for  and  avoided. 


STRANGULATED    INGUINAL    HERNIA. 


569 


overlying  the  grayish-blue  sac  looked  for.  The  surgeon  now  sees  if  he 
can  find  any  constricting  fibres  outside  the  sac,  and  slits  them  up  on 
a  director.  The  more  voluminous  the  hernia  the  more  important  it 
is  to  avoid  exposure  and  manipulation  of  its  contents  by  opening  the 
sac*  But  in  the  majority  of  cases  of  inguinal  hernia  the  surgeon 
must  be  prepared  for  opening  the  sac.  As  soon  as  this  is  done,  with 
the  precautions  already  given  (p.  562),  the  contents  are  examined, 

Fig.  98. 


(Fergusson.) 

omentum  got  rid  of  if  this  step  will  give  more  room,  and  the  site  of 
stricture  found  with  the  finger-nail  or  tip  of  the  director.  It  is  next 
divided  with  the  hernia-knife  manipulated  under  it  in  a  direction 
directly  upwards,  so  as  to  lie  parallel  with  the  deep  epigastric,  which- 
ever side  of  the  hernia  this  vessel  occupies.f  During  this  stage,  the 
steps  given  at  p.  563  must  be  taken  to  avoid  any  injury  to  the  intes- 
tine.    The  constricting  point  being  divided  and  dilated,  the  next  step 

*  Tiie  site  of  the  stricture  in  inguinal  hernia  varies.  In  both  varieties,  in  old  cases 
of  long  duration,  it  is  usually  situated  in  the  neck  of  the  sac  itself,  owing  to  contrac- 
tion and  thickening  of  this  and  the  extra-peritoneal  tissue.  In  other  cases  of  oblique 
hernia  the  stricture  is  found  in  the  infundibuliform  fascia  at  the  internal  ring,  just 
below  the  edge  of  the  internal  oblique  in  the  canal,  or  at  the  external  ring.  In  a 
direct  hernia  the  constricting  point,  if  not  in  the  sac,  is  probably  caused  by  the  fibres 
of  the  conjoined  tendon.  In  many  cases  the  parts  are  so  approximated  and  altered 
that  in  the  short  time  given  by  an  operation  it  is  not  so  easy  to  tell  exactly  in  what 
tissues  lies  the  strangulation,  as  to  relieve  it.  Finally,  in  many  cases  of  young  sub- 
jects and  acute  strangulation,  muscular  spasm — e.g.,  of  the  internal  oblique — must  be 
borne  in  mind. 

f  Of  course,  if  the  surgeon  is  certain  that  he  is  dealing  with  an  oblique  hernia,  he 
may  cut  outwards,  and,  in  the  case  of  a  direct  hernia,  inwards,  so  as  to  avoid  the  deep 
epigastric.  In  all  cases  the  cut  should  be  of  the  nature  of  a  nick  dividing  only  those 
fibres  which  actually  constrict,  any  additional  dilatation  being  usually  now  effected  by 
the  tip  of  the  director  or  finger. 


570 


OPERATIONS    ON    THE    ABDOMEN, 


is  reduction  of  the  intestine.  This,  in  l)ulky  inguinal  hcrnifc,  is 
often  a  matter  of  difHculty  and  time.  The  chief  Causes  of  cliflB- 
culty  here  are — (1)  A  large  amount  of  intestine,  one  or  two  coils  of 
small  and  some  large  intestine  being  not  very  uncommon.  (2)  The 
distension  of  these  with  flatus,  etc.     (3)  Insufficient  division  of  the 

Fig.  &P. 


(Skey.) 

stricture;  or  there  may  be  a  i)oint  of  stricture  higher  up  than  the  one 
divided,  and  overlooked.  (4)  During  attempts  at  reduction  one  bit 
of  intestine  may  get  jammed  across  the  ring  instead  of  slipping  up 
along  it,  and  against  this  the  rest  of  the  contents  are  fruitlessly  pressed. 
(5)  Folds  of  the  sac  may  in  much  the  same  way  block  tlie  opening. 

Aids  in  Difficult  Cases. — First,  that  part  which  lies  nearest  the 
ring  should  be  taken — e.r/.,  mesentery  before  intestine.  After  each  part 
is  got  up,  pressure  should  be  made  on  it  for  a  few  seconds  before  an- 
other is  taken  in  hand.  If  the  surgeon  find,  after  a  while,  that  he  is 
making  no  progress  with  one  end  of  a  coil,  he  should  take  in  hand 
the  other  end,  or  another  coil  altogether  if  more  than  one  is  present. 
During  the  manipulations  the  thigh  should  be  flexed  and  rotated  a 
little  inwards,  and  the  cut  edges  of  the  sac  drawn  tense  with  forceps, 
so  as  to  prevent  any  folding  or  pushing  up  of  this  before  the  intestine. 
If  the  intestines  are  much  distended,  attempts  should  be  made  to 


STRANGULATED    IXGUIXAL    HERXIA.  571 

return  some  of  their  contents  first  into  the  abdominal  cavity.  After 
by  gentle  squeezing  with  the  finger  and  thumb,  and  careful  pressure 
upwards  on  each  successive  bit  of  intestine,  it  all  appears  to  be 
returned,  the  little  finger  (aseptic)  must  be  passed  into  the  abdominal 
cavity  to  make  certain  that  no  knuckle  remains  in  the  canal  or 
internal  ring. 

Cases  will  occasionally  be  met  with  where,  owing  to  the  low.  con- 
dition of  the  patient,  the  large  amount  of  intestine  down,  its  great 
distension,  its  altered  condition,  still  red  and  only  congested,  but- 
softened,  with  the  peritoneal  coat  shaggy  rather  than  lustrous,  and 
tending  to  tear  easily,  it  is  clear  that  reduction  will  not  be  effected 
l)y  manipulation  only.  The  question  now  arises  which  of  these 
courses  is  the  wisest — to  make  a  small  incision,  empty  the  intestine,* 
and  then  to  suture  after  Lembert's  method  (Figs.  106, 107,  infra),  or  to 
tie  up  the  opening,  picked  up  on  a  pair  of  forceps,  with  carbolized  silk,f 
or  to  leave  the  intestine  in  the  sac  after  a  free  division  of  the  stricture. 
The  first  of  these  can  only  be  followed  when  the  intestine  is  healthy, 
and  thus  by  peristaltic  action  the  opening  in  the  muscular  coat  will 
be  carried  past  that  in  the  serous,  the  two  not  corresponding,  and 
when  aseptic  precautions  have  been  carefully  followed.  If  there  is 
an}'  doubt  about  these,  or  if  the  intestine  is  much  congested  and 
softened,  the  surgeon  had  best  be  content  with  a  free  division  of  the 
stricture  upwards  and  leave  the  intestine  in  the  sac.|  This  method 
is,  on  the  whole,  the  safer,  but  prevents,  of  course,  any  attempt  at 
relieving  the  i:»atient,  at  one  operation,  by  a  radical  cure. 

During  any  prolonged  manipulation  of  the  intestines  these  should 
be  kept  covered  as  much  as  possible  by  green  protective  Avrung  out  of 
warm  boracic  acid  or  carbolic  (1  in  80),  or  lint,  the  fluffy  side  being 

*  Wliile  the  intestine  is  emptying,  care  must  be  taken  to  lead  the  contents  well  away 
from  the  wound. 

t  The  ends  of  this  will  be  cut  short,  and  the  precautions  given  at  p.  5fi6  ni  case  of 
wound  of  the  intestine  in  herniotomy  followed. 

X  This  will  all  gradually  and  slowly  return  into  the  peritoneal  cavity.  ^  On  this  point 
the  following  case  by  South  (Chelius's  Surgery,  vol.  ii.  p.  40)  is  of  interest:  "I  know 
by  experience  that  if  strangulation  be  relieved,  it  is  of  little  consequence  how  much 
intestine  be  down.  In  reference  to  this  point,  I  recollect  the  largest  scrotal  rujiture 
on  which  I  have  operated,  and  in  which,  before  the  division  of  the  stricture,  there  was 
at  least  half  a  yard  of  bowel  down,  filled  with  air;  and,  after  the  stricture  had  been 
cut  through,  at  least  as  much  more  thrust  through,  so  that  I  almost  despaired  of  getting 
any  back ;  yet,  after  a  time,  I  returned  the  whole.  To  my  vexation,  however,  next 
morning  I  found  that  my  patient  had  got  out  of  bed  to  relieve  himself  on  the  chamber- 
pot, and,  as  might  be  expected,  the  bowel  had  descended,  and  in  such  quantitv  that 
the  scrotum  was  at  least  as  big  as  a  quart  pot,  and  the  vermicular  motion  of  the  intes- 
tine was  distinctly  seen  through  the  stretched  skin.  Nothing  further  was  done  than 
to  keep  the  tumor  raised  above  the  level  of  the  abdominal  ring,  and  by  degrees  it 
returned,  and  the  patient  never  had  an  untoward  symptom." 


572  OPERATIONS    ON    THE    ABDOMEN. 

turned  away  from  the  bowel.  I  prefer  also  to  stop  the  spray  during 
this  stage,  if  prolonged,  and  to  keep  the  neck  of  the  sac  as  much  cov- 
ered and  protected  as  possible.  It  is  wise  also  that  the  patient  should 
be  well  under  the  anaesthetic  now,  and  breathing  quietly.  If  vomit- 
ing occur,  the  surgeon  must  wait,  keeping  up  pressure  on  what  he 
has  reduced.  When  the  intestine  is  all  reduced,  any  ligatured  stumps 
of  omentum  are  returned,  and,  if  the  condition  of  the  patient  admits 
of  it,  the  sac  is  ligatured,  removed,  and  a  few  sutures  inserted  to  close 
the  dilated  canal  and  external  al)dominal  ring,  the  precautions  as  to 
the  cord  and  other  points  given  at  p.  583  being  carefully  followed. 

In  providing  drainage  after  an  o})eration  on  a  large  inguinal  hernia, 
where  the  parts  have  been  much  handled  either  before  or  during  the 
operation,  I  am  sure  it  is  well  worth  while  to  bring  the  lower  end  of 
the  drainage-tube  out  at  the  lower  part  of  the  scrotum,  by  means  of 
a  counter-puncture  there,  thus  ensuring  efficient  escape  of  the  dis- 
charges, and  syringing  out  of  the  wound  if  needful. 

After  thus  considering  the  chief  points  in  the  operation,  it  remains 
to  draw  attention  to  some  special  points  connected  with 
inguinal  hernia. 

I.  Varieties.^ — In  addition  to  the  oblique  and  direct  varieties,  both 
of  which  are  acquired,  there  are  some  others  of  much  practical  im- 
portance— e.g., 

(a)  The  congenital.  The  tubular  process  of  peritoneum  is  open 
from  abdomen  to  fundus  scroti,  and  the  contents  lie  in  contact  with 
the  testis. 

(b)  Hernia  into  the  funicular  process  of  peritoneum.  Here  the 
tubular  process  of  peritoneum  is  divided  into  a  shut  vaginal  sac 
below  and  an  open  funicular  process  above.  Into  the  latter  the  con- 
tents descend,  but  are  not  in  absolute  contact  with  the  testis. 

(c)  Hour-glass  contraction  of  the  sac.  Here  the  tubular  j)rocess  is 
open  as  in  («),  but  an  attempt  at  closure  has  brought  about  a  con- 
striction which  may  be  at  the  external  abdominal  ring  or  lower  down 
in  the  scrotum.  If  the  contents  pass  through  this  constriction,  and 
get  low  enough,  they  will  be  in  actual  contact  with  the  testis. 

(d)  Encysted  hernia  of  the  tunica  vaginalis.  Here  the  funicular 
process  is  closed  at  its  abdominal  extremity — i.e.,  at  either  ring  or  in 
the  canal — and  open  below  to  the  testicle.  Here  the  hernial  protru- 
sion as  it  comes  down  either  ruptures  the  septum  (when  of  sudden 
descent),  or  gradually  extends  and  inverts  it,  or  comes  down  behind 
it.  These  are  rare,  but  may  be  puzzling  when  they  occur,  as  the 
operator  has  more   than  one  layer  of  peritoneum  to  incise  before 

*  These  varieties  are  clearly  described  by  Mr.  Birkett  {Syst.  of  Surg.,  vol.  ii.  pp. 
798,  799,  Figs.  164,  165).  See  also  the  diagrams  in  Mr.  Bryant's  Surgery  (second 
edition),  vol.  i.  p.  601. 


STRANGULATED    IXGUIXAL    HERNIA.  573 

reacliing  the  contents,  two  or  three  bemg  met  with  according  as  the 
descending  hernia  has  brought  a  layer  of  parietal  peritoneum  with  it 
or  no,  and  according  as  the  septum  has  been  ruptured  or  stretched. 

That  the  above  varieties  have  an  importance  beyond  that  of  ana- 
tomical puzzles  is  shown  by  the  fact  that  in  (b),  (c),  and  (cZ)  strangu- 
lation may  be  very  acute  and  urgent.  Again,  though  the  defect  is  a 
congenital  one,  the  hernia  does  not,  in  many  cases,  make  its  appear- 
ance till  the  jDatient  has,  in  early  adult  life,  been  subjected  to  some 
sudden  strain.  Finally,  in  these  cases  any  prolongation  of  the  taxis 
will  be  not  only  futile,  but  actually  dangerous,  owing  to  the  tightness 
of  the  strangulation  and  the  facility  with  which,  owing  to  the  delicacy 
of  its  adhesions,  the  sac  may  be  separated  or  burst. 

II.  Reduction  en  masse,  and  Allied  Conditions.  —  These  have  been 
commonly  met  Avith  in  inguinal  hernise  owing  to  the  loose  connections 
of  the  sac  and,  sometimes,  to  the  force  used  in  attempts  at  reducing 
large  specimens.  Strangulation  may  persist  after  (a)  displacement, 
or  (6)  rupture  of  the  sac.  In  the  former,  the  sac,  still  strangling  its 
contents  at  its  neck,  is  displaced  bodily  between  the  peritoneum, 
usually,  and  extra-peritoneal  fascia.  In  the  latter,  the  sac  is  rent, 
usually  close  to  its  neck  and  at  its  posterior  aspect,  and  some  of 
its  contents  are  thrust  through  into  the  extra-peritoneal  connective 
tissue.  The  chief  evidence  of  these  accidents  is — Though  the  swelling 
has  disappeared,  perhaps  completely,  this  has  taken  place  without 
the  characteristic  jerk  or  gurgle.  On  close  examination,  though  the 
bulk  of  the  hernia  is  gone,  some  swelling,  often  tender,  is  usually  to 
be  made  out,  deep  down,  in  the  neighborhood  of  the  internal  ring. 
Above  all,  the  symptoms  persist,  perhaps  in  an  intensified  form. 

The  treatment  is  immediate  exploration  of  the  inguinal  canal  and 
the  internal  ring.  If  the  cord  is  exposed,  the  whole  sac  has  probably 
been  detached.  If  any  of  the  sac  is  left  above,  a  rent  in  it  should  be 
sought  for.  Supposing  the  index  finger,  passed  through  the  internal 
ring,  fail  to  find  any  swelling,  aided  by  pressure  from  without,  a  ver- 
tical incision  must  be  added  to  the  upper  end  of  the  oblique  one,  and 
the  neighborhood  of  the  internal  ring  explored.* 

III.  Retained  Testis  simulating  Hernia. — Such  a  testis,  when  in- 
flamed, may  closely  simulate  strangulated  hernia.  A  testis,  perhaps, 
has  never  descended ;  a  truss  has  been  Avorn  and  laid  aside.  The 
patient  jDresents  himself  with  a  tender  swelling  in  one  groin,  with 
indistinct  impulse.  The  abdomen  is  tense  and  full,  constipation  is 
present,  and  perhaps  vomiting  of  bilious  stuff.  Such  a  swelling 
should  be  explored  and  the  testis  removed,  as  it  is  certain,  later  on, 

*  As  tliis  will  probably  involve  abdominal  section,  the  steps  given  further  on 
should  be  referred  to. 


574  OPERATIONS  ON  THE  ABDOMEN. 

to  cause  serious  trouble,  even  if  the  present  urgent  symptoms  subside 
with  palliative  treatment.  In  other  cases  a  retained  testis  ma}^  draw- 
down 'an  adherent  loop  of  intestine  which  may  become  actually 
strangled.* 

STRANGULATED  UMBILICAL'   HERNIA. 

Two  distinct  forms  of  strangulated  hernia  will  be  met  with  here. 
One,  more  rare,  is  of  small  size,  with  a  single  knuckle  of  intestine 
acutely  strangled  in  the  navel-cicatrix.  The  other,  the  more  common, 
is  often  huge,  its  contents  mixed,  intestine  both  large  and  small,  and 
omentum.  Such  liernia?  soon  become,  in  part  at  least,  irreducible ; 
when  in  this  condition,  any  unwise  meal  may  readily  bring  about 
obstruction,  a  condition  requiring  much  care  to  tell  from  strangu- 
lation.f  In  other  cases  a  large  irreducible  hernia  may  easily  become 
strangulated  from  tlie  descent  of  some  additional  loop  of  bowel. 

Before  proceeding  to  operate,  it  is  well  to  bear  in  mind  these  practical 
points:  («)  The  sac  usually  communicates  directl}^  with  the  general 
peritoneal  cavity  by  a  large  opening,  {(i)  The  contents  are  not  only 
mixed,  but  of  long  standing,  and  often  adherent,  (y)  The  patients  are 
often  advanced  in  life,  stout,  flabby,  and  not  unfrequently  the  sub- 
jects of  chronic  bronchitis.  (S)  The  coverings  are  ill-nourished,  and 
slough  easily. 

Operation. — The  parts  having  been  cleansed,  and  an  anaesthetic 
administered,  an  incision  2  to  3  inches  long  is  made  over  the  lower  | 
part  of  the  swelling  in  the  middle  line,  the  hernia  being  somewhat 
pushed  upwards  to  facilitate  this.  The  thinness  of  the  coverings  must 
be  remembered,  after  the  layer  of  subcutaneous  fat  has  been  divided. 

*  For  fuller  inforiiiation  on  these  mntters  I  would  refer  my  readers  to  my  article 
on  "The  Disease  of  the  Male  Organs"  [Sijst.  of  Suuj.,  vol.  iii.  p.  471). 

f  Amongst  the  most  important  points  will  be  the  vomiting,  whether  early  in  onset, 
constant,  and  showing  signs  of  becoming  feculent ;  the  constipation,  whether  absolute, 
even  to  the  passage  of  flatus.  In  doubtful  cases  the  rule  should  be  to  operate.  "  The 
risk  of  operating  on  a  hernia  which  is  inflamed  and  not  easily  reducible  is  very  small 
in  comparison  with  the  risk  of  leaving  one  which  is  inflamed  and  strangulated  ;  and 
even  if  you  can  find  reasons  for  waiting  it  must  be  with  the  most  constant  oversight, 
for  an  inflamed  and  irreducible  hernia  may  at  any  time  become  strangulated,  and  will 
certainly  do  so  if  not  relieved  by  rest  and  other  appropriate  treatment"  (Sir  J.  Paget, 
loc.  supra  cit.,  p.  106). 

X  The  lower  part  is  here  recommended  because,  in  Mr.  Wood's  words  {Intern. 
Encycl.  of  Surg.,  vol.  v.  p.  1165),  "the  point  of  strangulation  in  an  adult  umbilical 
liernia  is  most  frequently  at  the  lower  part  of  the  neck  of  the  sac,  where  the  action  of 
gravity,  the  dragging  weight  of  the  contents,  and  the  superincumbent  fat,  together  with 
the  pressure  and  weight  of  the  dress  or  an  abdominal  belt,  combine  to  press  downwards 
upon  the  sharp  edge  of  the  abdominal  opening.  It  is  here  that  adhesions  and  ulcera- 
tion of  the  bowel  are  most  frequently  found,  and  iiere  the  surgeon  must  search  for  the 
constriction  in  cases  of  strangulation."     An  incision  here  also  gives  better  drainage. 


STRANGULATED    UMBILICAL    HERNIA.  575 

Search  should  be  made  for  any  constricting  bands  of  fibres  outside 
the  sac.  If  it  be  needful,  the  sac  must  be  opened,  with  the  knife  held 
horizontally,  and  slit  up,  care  being  taken  now  and  throughout  the 
operation,  in  cases  of  large  hernia,  that  protrusion  of  intestine  be  pre- 
vented by  the  means  given  a  little  later.  The  contents  having  been 
examined,  any  loops  of  intestine  are  gently  displaced  ujiwards,  while 
the  surgeon  turns  the  curved  surface  of  a  Key's  director  over  the  lower 
edge  of  the  opening,  and,  guiding  the  hernia  knife  on  this,  divides  the 
constricting  edge  downwards.  If  sufficient  space  is  not  given,  the 
downward  nick  may  be  rej^eated,  or  the  director  turned  against  the 
lateral  or.  upper  aspects  of  the  ring,  and  fibres  here  also  divided. 

Adhesions  of  the  contents  of  the  sac  are  not  unfrequently  met  with. 
If  they  are  very  close  and  dense,  and  if  the  condition  of  the  patient  is 
unsatisfactory,  the  surgeon  should  be  content  with  a  free  division  at  one 
or  two  places  of  the  constricting  ring,  and  with  reducing  any  portion 
of  intestine  that  has  clearl}^  only  recently  come  down,  and  leave  the 
rest  undisturbed. 

A  complication  of  large  umbilical  hernire  is  thus  well  described  by 
Mr.  Wood  {loc.  swpra  cit.,  p.  1168): 

"  In  corpulent  persons,  in  whom  the  operation  has  been  delayed 
until  peritonitis  has  begun,  the  operator  has  frequently  to  contend 
with  a  gush  of  bowels  out  of  the  abdomen.  This  should  be  restrained 
by  receiving  them  in  warm  towels  wet  with  carbolic  lotion,  and  ap- 
plying pressure  by  the  hands  of  assistants.  If  it  can  be  managed,  all 
the  operative  proceedings  within  the  sac  should  be  done  before  such 
a  rush  occurs ;  but  if  a  cough,  or  vomiting,  or  anaesthetic  difficulty 
occurs  at  this  juncture,  this  is  sometimes  impossible,  and  the  surgeon 
is  compelled  to  do  the  best  he  can.  In  such  cases  the  operation  be- 
comes a  formidable  one  indeed,  and  is  comparable  only  to  laparotomy 
under  conditions  of  distension  of  the  intestines.  The  bowels  and 
omentum  should  always,  if  possible,  be  kept  in  the  warm  wet  towels, 
and  not  indiscriminately  handled  by  the  assistants,  whose  arms 
should  be  bared,  and  well  purified  by  carbolized  lotion.  The  intestines 
should  always  be  returned  before  the  omentum,  which  should,  if  pos- 
sible, be  spread  out^'^  over  them  before  the  stitches  are  applied." 

All  the  intestine  and  the  remains  of  the  omentum,  carefully  liga- 
tured, being  returned  if  possible,  the  surgeon  now,  if  the  patient's 
condition  admits  of  it,  removes  the  redundant  sac  and  skin.  The 
opening  into  the  peritoneal  cavit}''  being  covered  with  a  veil  of  car- 
bolized lint,  the  sac  is  separated  from  its  connections  and  cut  away 


*  Mr.  Wood  prefers  leaving  the  edge  of  tlie  omentum  so  arranged  as  to  become  ad- 
lierent  to  tlie  lower  margin  of  the  hernial  opening,  so  as  to  prevent,  if  possible,  any 
future  protrusion,  to  tying  it  and  cutting  it  short. 


576  OPERATIONS  ON  THE  ABDOMEN. 

close  around  the  ring ;  any  bleeding-points  can  now  be  arrested  by 
numerous  strong  chromic-gut  ligatures  passed  through  the  edges  of  the 
ring  so  as  to  close  it  save  at  the  lower  part,  where  a  good  sized  drain- 
age-tube is  left  with  its  orifice'  flush  with  that  into  the  peritoneal 
cavity.  The  redundant  skin  is  then  cut  away  and  the  edges  of  the 
wound  brought  together  with  stout  silk  or  silver  sutures. 

It  will  be  s.een  from  the  above  account  that  tliree  methods  may  be 
pursued  in  the  reduction  of  a  strangulated  umbilical  hernia:  (1)  The 
division  of  the  stricture  outside  the  sac  (p.  560).  This  should  always 
be  tried,  but  is  rarely  successful  here.  (2)  If  the  sac  has  to  be  opened, 
the  opening  is  made  as  small  as  possible,  and  the  ring  freel^y  divided 
at  one  or  two  points,  but  the  contents  disturbed  as  little  as  possible, 
any  recently  descended  intestine  being  returned,  but  thickened 
omentum,  adherent  intestine,  especially  large,  being  left  undisturbed. 
(3)  Free  opening  of  the  sac,  examination  and  separation  of  its  con- 
tents, return  of  all  intestine,  and  of  omentum  after  ligature  and 
resection. 

While  the  third  of  these  courses  has  the  great  advantage  of  leaving 
the  patient  permanently  in  a  more  satisfactory  condition,  as  it  admits 
of  something  like  a  radical  cure,*  the  surgeon  can  only  rightly  decide 
between  this  and  the  second  course  by  a  careful  consideration  of  each 
case.  The  following  points  may  aid  in  judiciously  selecting  either 
operation :  (1)  The  size,  long-stariding,  previous  attacks,  of  incarcera- 
tion and  obstruction  of  the  hernia,  all  these  tending  to  bring  about 
adhesions  f  and  alterations  in  the  parts.  (2)  The  condition  of  the 
patient — viz.,  the  degree  of  flabby  fatness,  chronic  bronchitis,  probable 
renal  and  hepatic  disease,  amount  of  depression  by  vomiting  and  pain. 
(3)  The  facilities  for  carrying  out  during  the  operation,  and,  later, 
strict  aseptic  i)recautions.  (4)  The  presence  of  the  skilled  help  so 
essential  in  these  cases.  (5)  The  way  in  which  the  anaesthetic  is  taken. 
(6)  The  amount  of  experience  of  the  operator.  Thus  a  hospital  sur- 
geon frequently  operating  and  with  all  instruments  and  assistance  at 
hand,  may  readily  incline  to  one  course,  while  the  other  may  as  wisely 
be  followed  by  a  surgeon  who  has  to  operate  under  very  different  cir- 
cumstances. 

*  Tt  will  be  remembered  that  it  is  not  as  essential  to  try  and  ensure  a  radical  cure  in 
women  of  this  age  as  in  children  and  young  male  adults,  with  the  prospect  of  a  long 
and  active  life  before  them. 

t  Mr.  Clement  Lucas  {Clin.  Soc.  Trans.,  vol  xix.  p.  5)  advocated  more  radical  meas- 
ures, such  as  excision  of  the  sac  and  redundant  skin,  with  suture  of  the  ring,  in  all  cases 
of  umbilical  hernia.  Two  successful  cases  are  recorded,  both  excellent  instances  of  this 
treatment,  and  one  of  especial  interest,  as  the  patient  had  been  previously  thrice  tapped 
for  ascites,  and  the  operation  allowed  three  pints  and  a  half  of  fluid  to  escape. 


STRANGULATED    OBTURATOR    HERNIA.  577 


STRANGULATED  OBTURATOR  HERNIA. 

This  form  of  hernia  has  occurred  too  frequently  to  be  entirely  passed 
over.  It  may  be  so  readil}^  and  fatally  overlooked  that  a  few  words  on 
its  diagnosis  will  not  be  out  of  place. 

(1)  Position  of  the  swelling.  This  appears  in  the  thigh  below  the 
horizontal  ramus  of  the  pubes,  to  the  inner  side  of  the  capsule  of  the 
hip.  behind  and  just  inside  the  femoral  vessels,  behind  the  pectineus, 
and  outside  the  adductor  longus.  (2)  On  careful  comparison  of  the 
outline  of  Scarpa's  triangles,  a  slight  fulness  is  found  in  one  as  com- 
pared with  the  hollow  in  the  other.  (3)  Pain  along  the  course  of  the 
obturator 'nerve,  down  the  inner  side  of  the  thigh,  knee,  and  leg.  (4) 
Persistence  of  symptoms  of  strangulation,  the  other  rings  being  empty 
or  occupied  by  reducible  hernia.    (5)  A  vaginal  or  rectal  examination. 

Operation. — Two  different  ones  present  themselves:  (i.)  by  cutting 
down  on  the  sac  as  in  other  hernise;  (ii.)  by  abdominal  section,  and 
withdrawing  the  loop  from  within. 

(i.)  It  is  noteworthy  that  this  hernia  was  thus  first  successfully 
operated  on  by  a  general  practitioner,  Mr.  Obre. 

The  parts  being  duly  cleansed  and  slightly  relaxed,  an  incision  is 
made  parallel  to  and  just  inside  the  femoral  vein.*  The  saphenous 
opening  being  probably  exposed  in  part,  the  fascia  over  the  pectineus 
is  next  divided,  the  fibres  of  this  muscle  having  been  torn  through 
with  a  director,!  the  obturator  muscle  covered  by  its  fascia  and  some 
fatty  cellular  tissue  is  next  defined,  and  the  hernial  sac  probabl}'  now 
comes  into  view,  either  between  the  muscle  and  the  pubes,  or  between 
the  fibres  of  the  muscle.  If  the  case  is  a  recent  one,  attempts  are  now 
made  to  reduce  the  hernia  without  opening  the  sac.  If  the  sac  has  to 
be  opened,  and  any  constriction  divided,  the  knife  should  be  turned 
either  upward  or  downwards,  the  latter  being  the  easier  if  any  con- 
stricting fibres  intervene  between  the  sac  and  the  bone.  As  the  obtu- 
rator vessels  lie  usually  on  one  side  or  the  other,  a  Interal  incision 
must  be  avoided. 

Care  must  be  taken  to  keep  the  femoral  vessels  drawn  outward  with 
a  retractor,  while  any  branches  of  the  obturator  or  anterior  crural 
nerve  are  drawn  aside  with  a  blunt  hook,  the  same  precaution  being 
taken  with  the  saphena  vein. 

"When  by  the  passage  of  the  little  finger  into  the  abdomen  it  is  cer- 
tain that  the  intestine  is  reduced,  if  the  condition  of  the  patient  admits 

*  Mr.  Birkett  {loc.  supra  cit.,  p.  830)  says  the  incision  "may  commence  a  little  above 
Poupart's  ligament,  at  a  point  midway  between  the  spine  of  the  pubes  and  the  spot 
where  the  femoral  artery  passes  over  the  ramus  of  that  bone." 

t  If  it  will  give  more  room,  tliey  may  be  divided  transversely  for  1 J  to  2  inches,  as 
in  Mr.  Obr^'s  case. 

37 


578  OPERATIONS  ON  THE  ABDOMEN. 

of  it,  the  sac  is  separated  and  ligatured  close  to  the  thyroid  foramen 
and  removed.  Adequate  drainage  must  be  provided  before  closing 
the  wound. 

(ii.)  The  oj^eration  of  abdominal  section  will  perhaps  be  more 
frequently  performed  in  the  future.  An  obturator  hernia  was  thus 
reduced  by  Mr.  Hilton  in  a  case  which  simulated  intestinal  obstruc- 
tion. Some  empty  intestine  being  found  and  traced  downwards,  led 
to  the  detection  of  an  obturator  hernia,  which  was  reduced  by  gentle 
traction  aided  by  firm  pressure  made  deeply  in  the  thigh.  The 
patient,  who  was  not  operated  on  till  the  eleventh  day,  died,  within 
twelve  hours  of  the  operation,  of  rapid  peritonitis,  considered  by  Mr. 
Hilton  to  be  due  to  the  operation. 

Mr.  Erichsen  briefly  mentions  a  case  operated  on  by  this  means  in 
1884  by  Mr.  Godlee.  The  hernia  was  reduced  Avithout  difficulty,  but 
the  patient,  who  was  much  collapsed  at  the  time,  died  in  about  twenty- 
four  hours. 

The  duration  of  the  hernia  and  the  condition  of  the  patient  must 
be  considered  in  selecting  one  of  the  above  operations.  Where  the 
patient  is  much  exhausted,  the  shock  of  an  abdominal  incision  should, 
I  think,  be  avoided  ;  and  where  a  much  damaged  intestine  is  present, 
it  may  give  way  when  Avithdrawn,  causing  extravasation  into  the 
peritoneal  cavity, 

RADICAL  CURE  OF  HERNIA. 

Before  describing  the  different  methods,  the  following  points  claim 
attention,  and  while  the  improvements  of  modern  surgery  have  estab- 
lished radical  cure  on  a  sound  scientific  basis,  many  questions  remain 
quite  undecided. 

Permanency  of  cure.  Advisability  or  nee<l  of  wearing  a  truss. 
Term,  "  radical  cure."    Age. 

On  these  points  I  would  refer  my  readers  to  the  writings  of  Mr.  M. 
Banks,*  as  one  of  the  earliest  and  foremost  workers  at  this  subject, 
and  to  the  difficulty  of  some  of  his  cases  and  the  honest  frankness 
with  which  he  has  given  his  results.  His  experience  is  gained  from 
106  cases,  68  of  which  were  without  strangulation,  while  in  38  strangu- 
lation was  present.  Of  66  of  these  cases  in  which  he  was  able  to 
follow  up  the  result,  44  were  completely  successful,  7  partially  so — 
i.e.,  though  there  was  a  distinct  tendency  to  return,  the  hernia  could 
now  be  kept  up  by  a  truss,  a  thing  impossible  before. 

Mr.  Banks  considers  the  term  "  radical  cure  "  misleading.  "  It  is 
popularly  understood  that  a  patient  upon  whom  a  radical  cure  has 

*  Pamphlet,  loc.  infra  cit.;  Med.  Times  and  Gaz.,  1884  ;  Brit.  Med.  Journ.,  December 
10,  1887. 


RADICAL   CURE    OF    HERNIA.  579 

been  performed  need  never  acain  wear  a  truss  nor  ever  again  be  in 
danger  of  his  liernia  coming  down.  This  is,  unfortunately,  far  from 
being  the  case.  The  instances  in  which  a  light  truss  can  be  dispensed 
with  are  the  minority." 

Other  surgeons  appear  to  hold  a  different  opinion.  Thus,  Dr. 
Macewen,*  in  a  brilliant  series  of  cases — 81  in  all,  in  29  of  which 
strangulation  had  been  present — without  any  death,  merely  states 
that  48 1  subsequently  wore  a  pad  or  bandage. 

Mr.  Barker  J  has  had  no  death  in  a  series  of  41  cases.  Seven  of 
these  were  lost  sight  of;  of  the  others  recurrence  had  taken  place  in  5. 
He  does  not  recommend  the  use  of  trusses  except  in  cases  of  umbilical 
hernia. 

Many  other  surgeons  might  be  Cjuoted  as  deprecating  trusses  alto- 
gether, or  an}^  save  of  the  liglitest. 

Turning  to  foreign  surgery,  we  find  Prof.  Socin,  of  B&le,§  bringing 
forward  an  experience  of  136  operations,  71  being  for  strangulation. 
The  mortality  II  here  was  3.6  per  cent,  for  non-strangulated  cases. 
He  considers  that,  after  operation,  the  wearing  of  a  truss  is  not  per- 
missible as  long  as  a  relapse  has  not  occurred.^ 

While  it  will  be  at  once  granted  that  any  continuous  pressure  in 
the  form  of  a  pad  with  a  strong  spring  may  tend  to  weaken  the  in- 


*  Brit.  Med.  Journ.,  December  10,  1887. 

f  In  one  of  these  the  parts  were  firm  ;  in  the  others  support  was  worn  as  a  precau- 
tionary measure,  one  patient  being  of  lax  habit,  another  having  had  a  direct  hernia 
with  a  very  wide  opening,  while  the  occupation  of  the  third  demanded  much  exertion. 

X  Brit.  Med.  Journ.,  December  3,  1887.  Mr.  Barker  allows,  however,  that  in  one 
recurrence  the  patient  had  been  at  very  hard  work,  ever  since  the  operation,  without 
a  truss. 

f  Deut.  Zeit.f.  Chir.,  1886,  Bd.  xxiv.  Hft.  3  and  4;  Annals  of  Surgery.  March,  1887. 

II  Prof.  Socin  agrees  with  Mr.  Banks  as  to  large  hernia,  the  nmrtality  here  being 
40  per  cent.  The  mortality  at  Bale  after  simple  herniotociy  for  strangulated  hernia 
seems  to  have  been  decidedly  high — viz.,  24.3  per  cent.,  28  per  cent,  for  femoral,  and 
9.8  per  cent,  for  inguinal  cases, 

^  Several  other  conclusions  of  Prof.  Socin  will  well  bear  quoting  here:  (1)  Perma- 
nent cure  is  possible  ;  it  is  the  rule  in  recent  hernise  ;  in  older  ones  it  is  the  exception. 
(2)  Permanent  cure  is  more  prominent  in  those  who  have  not  completed  tlieir  growth, 
other  things  being  equal.  (3)  Prognosis  as  to  permanency  of  cure  is  unfavorably 
influenced  by  the  existence  of  another  hernia  in  the  patient,  as  well  as  by  a  family 
history  of  hernia.  (4)  Habitual  bodily  labor  appears  to  favor  a  jiermanent  cure; 
coughing,  on  the  contrarv,  tends  to  cause  relapse,  (o)  Probability  of  recurrence  con- 
stantly decreases  from  the  time  of  operation,  being  very  slight  indeed  after  the  lapse 
of  two  years.  (6)  The  most  favorable  method  of  performing  the  radical  cure  is  to 
ligate  the  sac  doubly  or  repeatedly  at  as  high  a  point  as  possible,  and  to  excise  it. 
Whether  the  ligature  of  tiie  sac  in  inguinal  herniaj  is  best  done  after  withdrawing  the 
sac  out  of  the  inguinal  canal,  or  after  incising  the  canal,  cannot  as  yet  be  finally 
decided.     Suture  of  the  constricting  ring  is  not  advisable. 


680  OPERATIONS    ON   THE    ABDOMEN. 

flammatory  thickening  resulting  from  the  operation,  most  surgeons 
will  prefer  that  their  patients  should,  for  some  years  at  least,  wear  a 
light  but  well-fitting  support,  especially  in  cases  where  the  hernia 
and  rings  have  alike  been  large,  where  the  work  involves  sudden 
strains,  or  where  the  patient  is  flabby  or  develops  an  habitual  cough. 

Indications. — The  following  are  given  only  as  tyi)cs  of  appropriate 
cases.     Many  others  will  suggest  themselves  : 

i.  Children  of  poor  and  ignorant  parents,  with  large  hernias,  where 
proper  attention  to  the  use  of  a  truss  cannot  be  secured.  It  will 
probably  be  justifiable  to  go  further  than  this,  and  to  operate  for  radi- 
cal cure  in  most  cases  of  hernia?  in  the  children  of  the  poor  in  which 
the  hernia  is  still  distinct  at  four  years  of  age.*  By  this  time  the 
parts  are  larger  and  more  easily  kept  sweet.  The  sac  is  more  easily 
dealt  with  now  than  later. 

ii.  Herniae,  especially  inguinal,  in  men  under  thirty-five,  interfering 
with  the  activity  of  life,  profitable  employment,  etc.  Subjects  of 
inguinal  herniae  with  adherent  omentum  are  never  really  safe,  espe- 
cially if  of  active  life. 

iii.  Small  femoral  hernia?  containing  irreducible  omentum.  These 
hernia)  are  difficult  to  fit  with  trusses,  and  the  omentum  keeps  the 
ring  open,  and  thus  paves  the  way  for  the  descent  of  bowel  on  any 
sudden  exertion. 

iv.  Large  herniae,  even  colossal,  where  the  patients,  unfitted  for 
work  of  any  kind,  are  a  burden  to  themselves  and  others,t  and  per- 
haps willing  to  run  great  risks  ;  for  it  cannot  be  denied  that  these  are 
very  grave  cases  :  "  The  operation  usually  difficult  and  prolonged, 
and  the  dangers  to  be  met  and  overcome  both  numerous  and  various  " 
(Banks).  The  best  proof  of  this  is  given  by  Mr.  Banks'  series  of  16 
very  large  and  enormous  hernise ;  of  these  he  lost  4, 2  from  septicaemia. 
In  another,  even  his  hands  failed  to  complete  the  operation. 

V.  I  consider  ten  to  twenty-five  years  of  age  as  the  most  favorable 
time,  as  combining  parts  easy  to  handle,  the  possibility  of  keeping 
the  wound  aseptic,  probable  absence  of  any  difficult  adhesions,  and 
good  vitality  and  health. 

Choice  of  Operation. — The  following  have  been  brought  promi- 
nently before  the  profession — viz. : 

*  This  age  is  mentioned  above  as  giving  time  for  trials  with  a  truss.  Before  deciding 
that  a  well-made  truss  will  not  keep  up  a  difficult  case — e.g.,  a  double  inguinal  hernia 
— the  hernia  should  be  completely  reduced  with  the  aid  of  an  anaesthetic. 

+  As  in  three  cases  given  by  Mr.  Banks:  one,  a  laborer  unfitted  for  work,  had 
become  an  inmate  of  a  workhouse ;  the  second  was  a  wine-merchant,  who  bad  been 
obliged  to  give  up  his  business,  rarely  venturing  out,  and  then  obliged  to  conceal  his 
deformity  under  a  large  overcoat;  the  third,  a  glass-blower,  reduced  to  perfect  help- 
lessness, bad  to  depend  on  his  wife  for  his  support. 


RADICAL    CURE    OF    HERNIA.  581 

i.  Operation  by  Open  Method  with  Strict  Aseptic  Pre- 
cautions. 

ii.  Subcutaneous  Methods— e.(/.,  Prof.  Wood's  and  Mr. 
Spanton's.. 

iii.  Injection  of  Astringents— ^'.f/.,  Oak  Bark. 

Of  these,  the  o])eration  by  open  method  will  be  described  first  and 
fully,  as  it  is  the  one  of  all  others  which  is  generally  chosen,  owing  to 
the  excellent  results  which  it  has  given,  the  precision  with  which  the 
structures  concerned  can  be  avoided  or  manipulated,  and  its  safety 
when  aseptic  precautions  are  strictly  observed.  There  is  no  doubt 
that  special  methods,  such  as  those  of  Prof.  Wood  and  Mr.  Spanton, 
give  excellent  results  in  the  experienced  hands  of  those  who  have  in- 
troduced them,  but  it  is  equally  certain  that  they  have  not  been  gen- 
erally adopted.  This  is  still  more  true  of  the  injection  method,  in 
this  country  at  least. 

i.  The  Operation  by  Open  Method  with  Strict  Aseptic 
Precautions.^ — The  patient  having  been  kept  in  bed  for  some  time 
before,  according  to  the  size  of  the  hernia,  any  cough  attended  to, 
only  liquid  diet  is  given  for  the  few  days  preceding  the  operation,  and 
the  bovv'els  are  duly  attended  to. 

The  parts  being  shaved  if  needful,  and  cleansed,t  the  thigh  being  a 
little  flexed,  an  incision  is  made  with  its  centre  over  the  external 
abdominal  ring,;]:  the  sac  itself  is  reached  and  made  certain  of. 

The  sac  being  defined  just  below  the  external  abdominal  ring,  the 
surgeon  must  make  up  his  mind  how  he  is  going  to  deal  with  it.  At 
least  the  four  following  courses  are  open,  and  all  are  well  deserving 
of  trial : 

A.  The  sac  being  freed  from  its  connections,  and  its  contents 
reduced,  it  is  ligatured  close  to  the  internal  ring,  and  the  fundus  cut 
away.  Two  or  three  silver  sutures  are  then  inserted  in  the  pillars  of 
the  ring  and  left  in  situ.,  the  object  of  the  sutures  being  merely  to  hold 
the  parts  together  temporarily  during  healing  (Banks). 

B.  The  sac,  separated  not  only  from  the  inguinal  canal,  but  also 
from  the  inner  surface  of  the  internal  ring,  is  reduced  into  the  abdo- 
men so  as,  bulwark-like,  to  protect  the  ring.§     While   this   is  the 

*  The  following  remarks  apply  to  inguinal  hernia. 

t  Dr.  Macewen  {loc.  infra  cit.)  recommends  scrubbing  with  a  nail-brush  and  soap 
and  water;  after  drying,  turpentine,  to  remove  any  grease,  and  then  a  little  methylated 
spirit  to  clear  away  tlie  turpentine,  the  parts  being  then  covered  with  lint  soaked  in 
some  aseptic  solution. 

X  Mr.  Kendall  Franks  advises  that  when  the  incision  above  is  made  parallel  to  the 
canal,  the  skin  should  be  drawn  down.  Thus  the  skin-wound  does  not  correspond  to 
the  sutures  buried  beneath,  and  is  further  removed  from  sources  of  sepsis. 

I  See  p.  583. 


582  OPERATIONS    ON    THE    ABDOMEN. 

primary  point,  the  canal  and  external  ring  are  most  carefully  closed 
with  sutures  (Macewen). 

C.  The  neck  only  of  the  sac  being  freed  (the  fundus  being  left 
in  situ),  this  is  tied  and  divided.  The  stump  is  then  pushed  up  into 
the  abdomen  while  the  rings  and  canal  are  closed  (Barker). 

D.  The  sac,  being  freed  quite  up  to  and  around  the  internal  ring,  is 
twisted,  and,  the  fundus  being  cut  away,  the  twisted  stump  is  secured 
in  situ  by  sutures  passed  through  the  external  abdominal  ring  (Ball). 

A.  Method  of  Banks.^ — The  sac,  having  been  made  certain  of,  is 
separated  from  the  cord  with  a  finger  or  steel  director,  the  vas  deferens 
being  taken  as  a  guide.  This  defining  of  the  sac,  and  its  separation, 
are  often  matters  of  difficulty — in  children,  owing  to  the  delicacy  of 
the  parts  and  the  minute  size  of  the  constituents  of  the  cord,  and  in 
adults  from  the  closeness  of  the  adhesions.  The  surgeon  may  easily 
think  he  has  reached  the  sac  long  before  he  really  has.  In  this  way 
the  parts  may  be  needlessly  interfered  with  and  strip})ed  off,  and, 
owing  to  oozing  into  opened-up  areolar  spaces,  landmarks  are  lost,  and 
suppuration  and  even  sloughing  may  occur. 

Care  must  be  taken  not  to  drag  the  testicle  out  of  its  bed.  In  con- 
genital cases,  to  avoid  needless  disturbance,  the  sac,  when  separated, 
should  be  cut  through  above  the  testis,  and  this  part  sutured  to  form 
a  tunica  vaginalis.f  The  cord  is  next  separated,  through  the  external 
ring,  up  into  the  canal  as  high  as  the  internal  ring,  the  finger  keeping 
note,  all  the  time,  of  the  position  of  the  cord.  If  the  sac  is  clearly 
empty,  its  neck  is  now  ligatvired  with  stout  chromic  gut  or  carbolized 
silk  as  high  up  as  to  leave  no  neck,  orifice,  or  dimple  at  the  internal 
ring.     The  fundus  is  then  cut  away  about  \  inch  below  the  neck. 

If  there  are  any  doubts  about  the  sac  being  empty,  a  small  opening 
is  made  and  the  little  finger  introduced  to  make  sure  of  this  point. 

If  it  be  needful,  owing  to  adhesions  of  intestine  or  presence  of 
altered  omentum,  the  sac  must  be  freely  opened,  adhesions  separated, 
and  the  omentum  tied  ;|:  and  cut  away  as  directed  at  p.  562,  and 
returned. 

While  the  omentum  is  being  examined  and  dealt  with,  an  assistant 

*  See  footnote,  p.  578. 

f  A  running  suture  of  chromic  gut  should  be  used  here.  I  employed  this  in  two 
cases  in  1887  in  a  child  of  five  and  a  man  of  twenty-two,  and  on  account  of  the  possi- 
bility of  hydrocele,  watched  these  artificial  tunicse  vaginales  with  much  interest  for 
some  months. 

;|:  If  the  surgeon  is  in  doubt  about  returning  any  stumps  of  omentum,  he  should 
retain  these  in  the  canal  by  his  sutures  passed  through  this  and  the  pillars.  It  will 
render  the  fitting  an  ordinary  truss  more  difficult,  but  not  one  with  a  horseshoe  pad, 
and  will  ultimately  shrink  and  blend  with  other  tissues.  Even  if  this  is  dela}ed,  it 
would  be  preferable  to  setting  up  peritonitis  by  returning  any  doubtful  omentum. 


RADICAL    CURE   OF    INGUINAL    HERNIA.  583 

must  keep  a  finger  carefully  on  the  canal  above,  to  prevent  any  slip- 
ping upwards  before  all  is  ligatured,  otherwise  grave  haemorrhage  may 
occur.* 

The  next  step  is  the  suturing  of  the  rings  and  canal.  While,  no 
doubt,  securely  ligaturing  the  neck  of  the  sac  as  high  up  as  possible 
is  the  first  point,  when  this  is  eSected,  the  above  structures  should  be 
as  carefully  sutured  as  possible,  if  time  and  the  condition  of  the 
patient,  etc.,  admit  of  it.  As  might  be  expected,  the  materials  used 
are  various — viz.,  wire,  carbolized  silk,  chromic  gut,  and  kangaroo 
tendon.  Mr.  Banks  uses  silver  wire  f  so  thick  that  a  single  knot  on 
it  will  suffice  to  make  it  hold  without  any  second  knot  and  without 
any  twisting.  The  wire  should  be  cut  very  close  to  the  knot,  so  as  to 
leave  no  projecting  sharp  ends. 

Chromic  gut  is  a  little  uncertain,  in  some  cases  soon  softening,  in 
others  coming  awa}'  but  little  changed,  with  points  of  suppuration.^ 
Carbolized  silk  is,  on  the  whole,  the  most  generally  applicable,  the 
twisted,  not  the  plaited,  kind  being  made  use  of.§ 

The  surgeon's  chief  object  in  passing  the  sutures  should  be  to  bring 
the  conjoined  tendon  as  close  to  Poupart's  ligament  as  possible,  at  a 
point  as  near  the  internal  ring  as  may  be,  so  as  to  make  the  canal 
again  a  mere  chink  or  valve  instead  of  a  short,  wide  tunnel. 

With  a  curved  needle  on  a  handle  (Fig.  100)  or  one  in  a  holder,  the 
finger-nail  being  insinuated  under  the  edge  of  the  conjoined  tendon 
on  the  outer  side  of  the  rectus  abdominis  the  needle  should  be  passed 
so  as  to  take  up  the  tendon  and  the  external  oblique  aponeurosis 
overlying  it,  the  cord  being  then  felt  for,  found,  and  pushed  upwards 
and  inwards,  the  needle  is  then  passed  through  Poupart's  ligament  as 
near  the  centre  as  possible.  In  passing  this  highest  and  most  im- 
portant suture  care  must  be  taken  to  avoid  the  deep  epigastric,  the 
cord,  and  the  iliac  vessels.  Other  sutures  ||  are  then  passed  (1) 
through  the  conjoined  tendon  and  external  pillar ;  (2)  through  the 
pillars  of  the  external  ring.  Before  any  sutures  are  tied  the  cord 
should  be  examined  and  found  free. 

Drainage  is  now  provided  with  a  bundle  of  horsehair,  and  the  skin 
wound  closed  with  silk  sutures.  The  dressings,  iodoform  and  sal 
alembroth  gauze,  are  applied  as  at  p.  564. 

*  This  precaution  will  also  meet  any  vomiting  and  re-descent  of  the  intestine. 

f  "  Its  hold  is  certain  and  enduring  beyond  that  of  any  other  suture,  while  it  is  as 
harmless  as  any"  (Banks,  Pamphlet,  pp.  13,  14). 

X  If  this  is  used  it  should  be  taken  from  a  sample  which  the  surgeon  has  tested  in 
operations,  and  the  final  soaking  shoidd  be  under  his  eye. 

§  Note,  p.  404. 

II  Three,  at  least,  if  possible,  in  a  large  hernia. 


584  OPERATIONS    ON    THE    ABDOMEN. 

B.  Macewen's  *  (Fig.  100). 

The  object  of  this  is  twofold  :  (1)  so  to  separate  the  sac  as  to  allow  of 
its  being  completely  reduced  into  the  abdominal  cavity,  there  to  rest 
on  the  inner  surface  of  the  circumference  of  the  ring,  and  as  a  bul- 
wark-like pad  to  "  shed  the  intestinal  waves  away  "  from  it.f  (2)  By  a 
particular  mode  of  inserting  sutures  to  bring  the  conjoined  tendon  in 
close  connection  with  that  part  of  Poupart's  ligament  which  is  on  a 
level  with  the  lowest  part  of  the  internal  ring. 

The  first  object  is  thus  insured.  The  external  ring  being  exposed 
(after  the  preliminaries,  footnote,  p.  581),  the  internal  ring  and  site  of 
the  deep  epigastric  are  examined,  and  the  sac  next  freed  and  raised. 
When  this  is  done  it  is  kept  pulled  down,  while  the  index  finger 
separates  the  sac  from  the  cord,  the  canal,  and  finally  for  i  inch 
around  the  abdominal  aspect  of  the  internal  ring. J  The  sac  is  now 
folded  on  itself  (Fig.  100)  by  means  of  a  stitch  which  is  firmly  fixed 
in  the  distal  end  of  the  sac.  The  free  end,  threaded  on  a  needle,  is 
introduced  through  the  canal  to  the  abdominal  aspect  of  the  fascia 
transversalis,  and  there  penetrates  the  abdominal  wall  about  1  inch 
above  the  internal  ring.  The  wound  in  the  skin  is  pulled  upwards  so 
as  to  allow  the  point  of  the  needle  to  project  through  the  muscles 
without  penetrating  the  skin.  The  needle  being  withdrawn  and  un- 
threaded by  traction  on  the  thread,  the  folded  sac  is  drawn  still 
further  backwards  and  upwards.  Traction  hfiving  been  kept  upon 
the  thread  while  the  sutures  are  introduced,  it  is  finally  secured  by 
passing  it  several  times  through  the  external  oblique  muscle. 

The  second  part  of  the  operation,  closure  of  the  inguinal  canal 
(Fig.  100),  is  now  undertaken.  The  finger  passed  into  the  canal  and 
lying  between  the  inner  and  lower  border  of  the  internal  ring  in  front 
of  and  above  the  cord,  makes  out  the  position  of  the  deep  epigastric 
artery  so  as  to  avoid  it. 

The  hernia-needle,  carrying  chromic  gut,  then,  guided  by  the  index, 
is  made  to  penetrate  the  conjoined  tendon  in  two  places,  first  from 
without  inwards  (a)  near  the  lower  border  of  the  conjoined  tendon, 
and  secondly  from  within  outwards,  as  high  up  as  possible,  in  the 
inner  aspect  of  the  canal  (b),  this  double  penetration  of  the  conjoined 
tendon  being  accomplished  by  a  single  screw-like  turn  of  the  instru- 
ment.    One  end  of  the  suture  is  then  withdrawn,  and  then  the  needle, 

*  Ann.  of  Surg.,  August,  18S6 ;  Brit.  Med.  Journ ,  December  10,  1887,  with  nine 
woodcuts. 

t  Dr.  Macewen  thinks  tliat,  however  carefully  and  high  up  the  sac  is  tied,  there 
remains  a  funnel-shaped  puckering,  the  apex  of  which  presents  in  the  internal  ring, 
and  that  this  pouch  gradually  becomes  a  wedge,  tending  to  open  up  the  canal. 

X  All  this  is  done  through  the  original  small  incision,  "sufficient  to  expose  the 
external  abdominal  ring." 


RADICAL    CUKE    OF    INGUINAL    HERNIA. 


585 


Avith  the  other  end  is  removed.     Thus,  a  loop  is  left  at  the  abdominal 
aspect  of  the  conjoined  tendon. 

Secondly  the  other  hernia-needle,  threaded  with  that  part  of  the 
suture  which  comes   from  the  lower  part  of  the  conjoined  tendon 

Fig.  100. 


On  the  left  is  one  of  Dr.  Macewen'.s  needles.  They  are  made  of  one  piece  of  steel.  In  the 
middle  is  the  folded  sac.  The  right-hand  figure  (modified  from  those  of  Dr.Macevven)  Is 
intended  to  .<ho\v  his  mode  of  suturing  the  internal  ring.  The  index  finger  in  front  of  the 
folded  sac  is  separating  the  peritoneum  round  the  internal  ring.  The  suture  a,  6,  has  pene- 
trated the  conjoined  tendon  at  two  places,  first  from  without  inwards  near  its  lower  border, 
and  secondly  from  within  outwards,  as  high  up  as  possible,  a  loop  being  thus  left  on  the  abdo- 
minal aspect  of  the  conjoined  tendon.  At  a'  and  b'  the  two  ends  of  the  above  suture  have  been 
passed,  separately  threaded  on  needles,  from  within  outwards,  through  Poupart's  ligament 
below,  and  through  the  transversalis  and  obliques  above. 

(a'),  guided  by  the  index  in  the  inguinal  canal  is  passed  from  within 
outwards,  through  Poupart's  ligament,  which  it  penetrates  at  a  point 
on  a  level  with  the  lower  suture  in  the  conjoined  tendon.  The  needle 
is  then  completely  freed  from  the  suture  and  withdrawn. 

Thirdl3^  the  needle  now  threaded  with  that  part  of  the  catgut 
which  protrudes  from  the  upper  border  of  the  conjoined  tendon  (6'), 
is  passed  from  within  outwards  through  the  transversalis  and  internal 
oblique  muscles  and  the  aponeurosis  of  the  external  oblique  at  a 
point  on  a  level  with  the  upper  stitch  in  the  conjoined  tendon.  It  is 
then  quite  freed  from  the  suture  and  withdrawn.  There  are  now  two 
free  ends  in  the  outer  surface  of  the  external  oblique,  continuous 
with  the  loop  of  the  abdominal  surface  of  the  conjoined   tendon. 


586  OPERATIONS    ON   THE    ABDOMEN. 

The  two  free  ends  being  drawn  together  tightly,  and  tied  as  a  reef- 
knot,  the  internal  ring  is  firmly  united.  The  same  stitch  may  be  re- 
peated lower  down  in  the  canal,  especially  in  adults  with  wide  gaps. 
The  pillars  of  the  external  ring  may  likewise  be  brought  together.  In 
the  great  majority  of  cases  the  first  or  uppermost  stitch  is  all  that  is 
required.  The  cord  should  lie  behind  and  below  the  sutures  and  be 
freely  movable  in  the  canal.  It  is  advisable  to  introduce  all  the 
sutures  before  tightening  an}'^  of  them.  They  may  then  be  experi- 
mentally drawn  tight  while  a  finger  is  introduced  into  the  canal  to 
learn  the  result.  During  the  operation  the  skin  is  drawn  from  side  to 
side  to  bring  the  parts  into  view.  The  skin  falling  into  position,  the 
wound  is  opposite  to  the  external  ring,  the  operation  being  partly 
subcutaneous. 

C.  Barkerls.^ — This  operation  is  similar  to  the  above  in  that  the  sac 
is  fixed  by  a  suture  to  the  internal  ring,  but  difi'ers  from  it  and  all 
others  in  the  fact  that  the  scrotal  portion  of  the  sac  is  left  in  situ. 
The  rings  and  the  canal  are  carefully  closed  with  sutures. 

The  neck  of  the  sac  being  exposed  f  and  cleared  with  all  due  care 
of  the  cord,  two  stout  silk  threads  are  now  passed  round  this  close  to 
the  external  ring,  precautions  being  taken  not  to  include  the  cord,  or 
any  intestine  or  omentum.  The  threads  being  tied,  the  sac  cut  across 
between  them,  and  the  scrotal  portion  left  in  situ  tied  and  with  its 
ligature  cut  short,  one  of  the  upper  threads  on  the  neck  of  the  sac 
threaded  in  a  Lister's  needle  is  passed  up  the  inguinal  canal,  in  front 
of  the  vas,  and  guided  by  the  left  index,  which  pushes  the  sac  before 
it  and  feels  for  the  inner  aspect  of  the  abdominal  ring.  Here  the 
needle  is  passed  through  one  border  of  the  ring  and  out  through  the 
external  oblique.  It  is  again  unthreaded  and  withdrawn,  and  carry- 
ing the  other  thread  is  passed  up  the  canal  and  then  through  the 
opposite  side  of  the  ring  and  the  external  obliqvie.  When  these 
threads  are  knotted  securely  the  stump  is  withdrawn  within  the  ab- 
domen, and  the  internal  ring  is  also  closed.  Three  or  four  more 
sutures  are  then  passed  thus.  The  needle,  again  carrying  silk,  is 
passed  up  the  canal  and  pushed  from  within  outwards  through  one 
of  the  walls  high  up,  the  cord  being  protected  as  before  by  the  left 
index.  It  is  then  withdrawn,  still  threaded,  but  leaving  one  end  of 
the  silk  through  the  tendon,  and  is  then  made  to  puncture  the  other 
wall  at  a  corresponding  point,  where  it  is  unthreaded  and  withdrawn. 
All  sutures  pass  in  front  of  the  cord,  and  the  lowest  should  not  close 
the  ring  too  tightly  upon  it. 


*  Brit.  Med.  Journ.,  December  3,  1S87;  Man.  of  Oper.  Surg.,  p.  334,  Fig  51. 
f  The  incision  is  represented  as  exposing  both  rings  and  the  canal. 


RADICAL    CURE   OF    INGUINAL    HERNIA.  587 

D.  BaWs.^ — Here  the  sac  is  twisted,  the  fundus  cut  away,  and  the 
stump  stitched  in  the  ring. 

1.  The  sac  being  completely  isolated  right  up  to  the  internal  ring, 
and  ascertained  to  be  empty,  is  gradually  twisted  up  by  a  broad-catch 
forceps  grasping  its  neck,  while  the  left  fore-finger  frees  the  upper  part 
of  the  neck.  In  ordinary  cases,  four  to  five  complete  revolutions  are 
sufficient,  but  this  must  depend  on  the  thickness  of  the  sac,  the  torsion 
being  continued  till  it  is  felt  to  be  quite  tight  and  likely  to  rupture. 
An  assistant,  now  holding  the  torsion  forceps,  maintains  the  twist, 
while  a  stout  catgut  ligature  is  tied  tightly  round  the  twisted  neck  and 
cut  short.  Two  sutures  of  stout  aseptic  silk  are  now  passed  through 
the  skin  about  i  inch  from  the  edge  of  the  wound,  through  the  outer 
pillar  of  the  ring,  through  the  twisted  sac  in  front  of  the  catgut  suture, 
and  then  through  the  inner  pillar  and  skin.  As  the  sac  now  cannot 
untwist  it  is  cut  off  in  front  of  these  sutures,  which  are  tied  over 
leaden  plates,  which  lie  at  right  angles  to  the  wound. 

2.  Subcutaneous  Methods— e. .7. ,  those  of  Mr.  Wood  and 
Mr.  Spanton. — Successful  as  these  have  been  in  the  hands  of  their 
authors  they  have  never  been  largely  adopted  by  surgeons.  Important, 
no  doubt,  as  is  the  subcutaneous  principle  in  surgery,  there  is  a  wide 
difference  betw^een  it  wdien  applied  to  division  of  tendons,  and  to  the 
taking  up  with  wire  or  corkscrew  enough  of  important  parts  to  ensure 
a  good  result,  while  at  the  same  time  other  most  important  structures 
— e.g.,  peritoneum,  vessels  and  cord — must  be  left  untouched.  The 
difficult}'  of  making  sure  of  enough  inflammation,  adhesion  and  con- 
solidation, the  feeling  that  a  certain  amount  of  suppuration  is  needful 
to  ensure  loosening  and  removal  of  the  wire  or  corkscrew,  and  that 
this  suppuration  may  lead  to  serious  results,  while  the  having  to  remove 
a  foreign  body  may  break  down  much  of  the  good  done,  are,  it  seems 
to  me,  powerful  objections. 

Wood^s  Method.^ — The  rupture  being  completely  reduced,  an  oblique 
incision,  1  inch  long,  is  made  over  the  fundus  of  the  sac.  The  skin  is 
separated,  with  the  handle  of  the  knife,  from  the  deep  coverings  of  the 
sac  for  about  1  inch  all  round.  The  fore-finger  is  then  passed  into  the 
wound,  and  the  detached  fascia  and  fundus  invaginated  into  the  canal. 
The  finger  then  feels  for  the  lower  border  of  the  internal  oblique,  lifting 
it  forwards  to  the  surface.  By  this  means  the  outer  edge  of  the  con- 
joined tendon  is  felt  to  the  inner  side  of  the  finger.  The  needle 
(stout,  semicircular,  in  a  strong  handle)  is  then  carried  carefully  up 
to  the  point  of  the  finger  along  its  inner  side  and  made  to  transfix  the 
conjoined  tendon,  and  also  the  inner  pillar  of  the  superficial  ring. 

*  Brit.  Med.  Journ.,  December  10,  1887. 

*  Intern.  Encycl.  of  Surg.,  vol.  v.  p.  1040. 


588  OPERATIONS  ON  THE  ABDOMEN. 

When  the  point  is  seen  to  raise  the  skin,  the  latter  is  drawn  over  to  the 
middle  line,  and  the  needle  made  to  pierce  it  as  far  out  as  possible. 
The  wire  (stout,  silvered  copper  about  2  feet  long)  is  then  hooked  into 
the  eye  of  the  needle,  drawn  back  with  it  into  the  scrotum  and  then 
detached.  The  finger  is  next  placed  behind  tlie  outer  pillar  of  the 
ring,  and  made  to  raise  that  and  Poupart's  ligament  as  much  as  pos- 
sible from  the  deeper  structures.  The  needle  is  then  passed  along  the 
outer  side  of  the  finger,  and  pushed  through  Poupart's  ligament  a 
little  below  the  deep  hernial  opening.  The  point  is  then  directed 
through  the  same  skin  puncture  before  made,  the  other  end  of  the  wire 
hooked  on  to  it,  drawn  back  into  the  scrotal  puncture  as  before,  and 
then  detached.  There  is  now  a  wire-loop  at  the  groin,  and  two  hook- 
ends  at  the  scrotal  puncture.  Opposite  the  latter  the  sac  is  then  pinched 
up  by  the  finger  and  thumb,  in  the  same  way  that  a  varicocele  is  sepa- 
rated from  the  spermatic  duct  when  submitted  to  operation.  An 
assistant  seizes  it  with  finger  and  thumb,  also  in  the  same  way,  at 
about  2  inches  distance,  both  assistant  and  operator  recognizing  the 
situation  of  the  spermatic  duct.  The  needle  is  then  passed  at  one 
corner  of  the  scrotal  puncture,  across  the  sac  in  front  of  the  duct,  and  out 
at  the  other  end  of  the  scrotal  puncture.  The  skin  here  is  so  elastic  that 
it  stretches  so  as  to  allow  this  easily  to  be  done.  The  inner  end  of  the 
wire — viz.,  that  traversing  the  conjoined  tendon — is  next  hooked  into 
the  needle  and  drawn  across  behind  the  sac.  Care  must  be  taken  by 
dealing  with  the  wire  roundly,  not  to  make  an  acute  bend  or  kink 
which  would  put  a  needless  difficulty  in  the  way  of  its  subsequent 
withdrawal.  The  two  scrotal  wires  are  now  twisted  twice  or  three 
times  together,  the  operator  observing  the  direction  of  the  twist,  so  as 
to  be  able  readily  to  untwist  the  wire  when  it  has  to  be  withdrawn. 
The  loop  above  is  now  drawn  firmly  upwards  so  as  to  invaginate  the 
scrotal  fascia  into  the  canal  up  to  the  internal  ring,  and  is  then  twisted 
down  with  the  same  precautions  as  the  lower,  and  the  two  loops  are 
bent  down  and  secured  over  a  pad  of  lint,  a  little  carbolized  tow  serving 
to  catch  any  discharge.  The  wire  should  be  left  in  eight  to  twelve  days 
according  to  the  amount  of  reaction.  The  wire  is  then  untwisted  and 
withdrawn  by  cutting  off  the  lower  ends  and  pulling  on  the  upper. 
One  of  Mr.  Wood's  horseshoe  trusses  is  then  worn  for  a  few  months. 

Sjjanton''s  Method.^ — This  is  based  on  Mr.  Wood's,  but  is  believed  to 
have  the  advantage  of  drawing  the  pillars  of  the  ring  more  securely 
together.  The  instruments  required  are,  a  large  tenotomy  knife  and  a 
screw  instrument,  shaped  like  a  corkscrew,  but  with  the  screw  rather 
broader  at  the  point. 

The  hernia  being  carefully  reduced  and  kej^t  up,  an  incision  is  made 
in  the  scrotal  skin  over  the  fundus,  generally  about  2  inches  below  the 

*  Brit.  Med.  Journ.,  December  11,  1880. 


RADICAL    CURE   OF    FEMORAL    HERNIA.  589 

pubic  spine,  large  enough  to  admit  the  tinger  easily,  and  the  skin  sepa- 
rated from  the  parts  beneath  Avith  the  handle  of  a  scalpel,  to  an  extent 
determined  by  the  size  of  the  hernia  and  that  of  the  canal.  In  order 
to  choose  an  instrument  of  proper  size  a  careful  examination  is  now 
made  of  the  rings,  length  of  the  canal,  surrounding  vessels,  etc.,  with 
the  left  forefinger,  which  is  passed  up  to  the  deep  ring  invaginating  the 
fascia  and  hernial  sac.  The  finger  here  is  retained  in  the  canal,  pro- 
tecting the  cord,  and  at  the  same  time  closing  the  deep  ring.  The  screw 
dipped  in  carbolic  oil  is  thrust  through  the  skin  of  the  groin  so  as  to 
transfix  the  aponeurosis  of  the  external  oblique,  at  a  point  somewhat 
above  that  at  which  it  is  intended  to  pass  through  the  conjoined  tendon. 
Having  given  the  instrument  one  half  turn  to  the  right,  if  a  right 
inguinal  hernia,  and  a  whole  turn  if  it  be  a  left  one,  it  is  next  made 
to  pierce  subcutaneously  the  conjoined  tendon  as  high  up  as  can  safely 
be  reached,  the  left  forefinger  carefully  guarding  the  point  fi'om  in- 
juring vessels  or  peritoneum.  This  part  of  the  operation  must  be 
done  continuously  and  deliberately.  It  will  then  be  found  that  as 
soon  as  a  hold  has  been  secured  by  the  instrument  the  ring  is  practi- 
cally closed.  Another  turn  is  now  given  to  the  screAv,  causing  it  to  pass 
through  the  invaginated  tissue — whether  fascia  or  sac,  or  both — and 
it  is  again  passed  througli  the  outer  pillar,  and  then  across  the  inner 
pillar  of  the  external  ring,  and  another  turn  given,  if  possible,  so  as 
to  bring  the  point  out  at  the  wound  in  the  scrotum.  The  handle  should 
then  lie  flatwise  on  the  abdomen,  and  the  point  be  protected  by  some 
carbolized  gauze.  The  amount  of  induration  excited  will  be  the  guide 
as  to  the  removal  of  the  instrument,  but  a  week  has  usually  been 
found  sufficient.  The  removal  is  easy,  by  keeping  the  instrument  well 
oiled,  and  by  the  loosening  result  of  sup})uration.  Mr.  S.panton  ad- 
vises the  temporary  use  of  a  truss. 

iii.  Injection  of  Astringents. — I  am  unable  to  find  space  for  an 
account  of  this  method.  The  full  account  given  of  the  open  method 
will,  I  believe,  meet  all  cases.  That  by  injection  has  found  no  favor 
amongst  English  surgeons. 

RADICAL  CURE  OF  FEMORAL  HERNIA. 

There  is  very  much  less  necessity  for  this,  women,  in  whom  it  is  so 
much  more  frequent,  finding  a  truss  more  efficient  and  less  irksome, 
owing  to  their  less  active  life  and  mode  of  dress.  Omental  femoral  hernia 
(p.  580)  should  be  operated  on  when  there  is  the  least  difficulty  in  fit- 
ting, or  unwillingness  to  wear,  a  truss,  the  sac  being  always  ligatured 
and  taken  away.  The  same  course  should  be  followed  in  all  cases  of 
strangulated  femoral  hernia,  when  the  condition  of  the  patient  admits 
of  it,  care  being  always  taken  to  make  the  smallest  nick  possible  in 


590  OPERATIONS  ON  THE  ABDOMEN. 

Gimbernat's  ligament,  so  as  to  minimize  the  risk  of  recurrence.     The 
steps  have  been  fully  given  at  p.  561. 

Mr.  Wood  has  introduced  a  subcutaneous  wire  operation  for  reducible 
femoral  hernia  analogous  to  that  already  given  for  the  invagination  of 
the  sac  in  inguinal  hernia.* 

RADICAL  CURE  OF  UMBILICAL  HERNIA. 

This  operation  is  very  rarely  called  for,  as  in  children  the  tendency 
to  a  natural  cure  is  so  marked,  and  in  adults  the  condition  both  of 
the  patient  and  the  rupture  is  usually  so  unfavorable  (pp.  574,  576). 

In  those  rare  cases  in  children  where  the  operation  is  justifiable 
from  the  large  size  of  the  ring,  and  the  want  of  improvement  under 
the  surgeon's  own  eye,  the  ring  should  be  closed,  with  strict  aseptic 
precautions.  To  such  cases  an  operation  of  Mr.  Keetley's  f  is  well 
adapted.  The  sac  being  separated  and  twisted,  as  in  Mr.  Ball's 
method  (p.  587),  a  stout  catgut  suture  is  passed  through  it,  and  the 
peritoneum  being  very  carefully  separated  from  the  linea  alba  above 
the  ring,  a  needle  is  passed  up  into  the  space  thus  made,  carrying  the 
catgut,  threaded,  through  the  sac,  and  brought  out  through  the  linea 
alba.  Then,  on  j^ulling  the  catgut  tight,  the  twisted  sac  is  drawn  into 
the  space  between  the  peritoneum  and  the  linea  alba.  The  edges  of 
the  hernial  aperture,  now  freed,  are  pared  and  brought  together  with 
pins  and  twisted  suture. 

Mr.  Wood  has  also  described  a  subcutaneous  wire  operation  for  the 
cure  of  these  cases. J 

In  the  account  of  the  operation  for  strangulated  umbilical  hernia 
(p.  575),  the  steps  for  taking  away  the  sac  and  the  redundant  skin, 
and  suturing  the  ring,  are  given. 


CHAPTER    III. 

COLOTOMY. 

Under  this  term  are  included  the  operation  of  opening  the  ascend- 
ing or  descending  colon  in  the  loin,  or  lumbar  colotomy — an  operation 
with  which  the  name  of  Amussat§  is  justly  associated — and  also  the 
anterior  colotomy  of  Littre,  in  which  the  sigmoid  colon  is  opened  in 
the  left  iliac  region. 


*  Intern.  Ene^d.  of  Surg.,  vol.  v.  p.  1160,  Figs.  1147,  1148. 
f  Jtinafe  o/ iSwrf/er!/,  September,  1887. 
j  Loc.  supra  cit.,  p  1169,  Figs.  1150-1154. 

§  Students  are  often  perplexed  as  to  the  difference  between  Amussat's  and  Callisen's 
operations.     Callisen  (1796)  was  the  first  to  suggest  such  an  operation  as  colotomy, 


LUMBAR   COLOTOMY.  591 

LUMBAR,  OR  POSTERIOR,  COLOTOMY   (Figs.   101,   102). 

Indications. 

(1)  Malignant  disease  of  rectum  not  admitting  of  dilatation. 

(2)  Venereal,  syphilitic  stricture  of  rectum,  in  which  previous 
treatment,  including  dilatation,  has  failed,  and  in  which  proctotomy* 
is  not  available. 

In  either  of  the  above,  extensive  ulceration,  much  pain,t  loss  of 
sphincter  power,  profuse  blood  stained  or  fseco-purulent  discharge 
from  the  boAvel  or  multiple  fistulse,  abundantly  justify  the  operation. 

It  is  in  such  cases  as  those  where  the  symptoms  are  not  yt^t  very 
urgent  that  the  surgeon  will  find  most  difficulty  in  deciding  when  to 
advise  colotomy.  When  intestinal  obstruction  is  actually  impending, 
the  patient  will  be  anxious  to  submit,  owing  to  the  amount  of  pain 
and  distress  actually  present,  and  the  surgeon  will  be  ready  to  per- 
form an  operation,  even  if  the  duration  of  life  may  be  but  brief.  But 
to  return  to  less  urgent  cases,  the  patient  or  the  friends,  especially  if 
in  a  better  rank  of  lile,  will  frequently  expect  a  decided  answer  as  to 
the  amount  of  relief,  and  also  the  amount  of  annoyance  which  will 
follow  on  an  artificial  anus.  Before  attempting  to  give  any  data  on 
which  an  answer  may  be  founded,  I  would  say  that  I  think  the  more 
frequently  a  surgeon  performs  this  operation  the  more  will  he  admit 
that  there  are  cases,  occasional  no  doubt,  in  which  this  operation, 
though  well  performed,  fails  to  give  the  expected  amount  of  relief. 

Putting  aside  cases  where  the  operation  is  performed  too  late,  and 

where  the  local  mischief  has  been  allowed  to  become  too  advanced, 

■  those  where  secondary  deposits  exist,  cases  where  the  opening  has 

been  too  free,  or  where,  with  a  proper  opening,  a  constant  cough,  aided 

by  a  relaxed  condition  of  tissues,  tends  to  bring  about  a  worrying 

and  planned  to  open  the  descending  colon  by  a  vertical  incision.  This  proposal  was 
condemned  by  contemporary  surgeons.  Amussat  revived  tlie  retro-peritoneal  opera- 
tion, if  he  was  not  the  first  to  perform  it,  but  modified  it  by  extending  it  to  tlie  ascend- 
ing and  descending  colon  alike,  and  by  making  use  of  the  transverse  incision.  Long 
before  Amussat's  time,  Littre(1710)  had  opened  the  sigmoid  flexure  through  the  peri- 
toneum, and  in  1776  Pillor^  had  opened  the  caecum. 

f  Linear  division  of  a  non-malignant  stricture  posteriorly.  If  a  finger  cannot  be 
passed  through  the  stricture,  this  is  first  divided  with  a  probe-pointed  bistoury  to 
admit  the  finger.  Then  a  curved,  sharp-pointed  bistoury,  passed  through  the  stricture, 
is  made  to  transfix  the  bowel  beyond  the  stricture,  and  the  point  is  brought  out  close 
to  the  tip  of  the  coccyx.  The  parts  are  then  cleanly  divided  by  cutting  out  towards 
the  anus  in  the  middle  line.  In  about  ten  days  the  u'^e  of  bougies  is  commenced.  For 
a  good  account  of  this  excellent  operation,  see  Mr.  Cripps's  Dis.  of  the  Rectum  and  Anus 
p.  239. 

J  In  a  few  and  exceptional  cases  cancer  of  the  large  intestine  may  run  its  course, 
set  up  visceral  deposits,  and  kill  the  patient  with  very  little  pain. 


592  OPERATIONS  ON  THE  ABDOMEN. 

prolapsus,  putting  aside  cases  in  which  the  opening  was  perhaps 
originally  too  small,  or  in  which  the  patient  does  not  take  the  trouble 
to  keep  the  opening  dilated  as  directed,  I  am  of  opinion  that  occasion- 
ally causes  of  failure  to  give  complete  relief  are  met  with  after  an 
operation  quite  properly  carried  out.  While  I  cannot  give,  and  have 
failed  to  meet  with,  an  explanation  for  every  case,  I  think  the  follow- 
ing are  bona  fide  causes,  and  without  detracting  seriously  from  the 
value  of  this  excellent  operation,  because  only  occasional,  I  feel  that 
they  have  been  somewhat  unduly  overlooked,  and  tliat  there  is  too 
great  a  tendency  amongst  writers  on  colotomy  to  teach  that,  if  it  is 
done  sufficiently  early,  and  if  its  immediate  risks  are  survived,  the 
relief  is  always  decided  and  the  patient's  condition  always  a  most 
satisfactory  one. 

Some  of  these  instances  of  incomplete  relief — viz.,  persistent  passage 
of  motions  over  the  malignant  disease,  and  teasing  diarrhoea  from 
the  artificial  and  natural  anus,  have  seemed  to  me  to  be  due  :  (1)  To 
the  lower  communication  with  the  bowel  being  too  patent,  sometimes 
no  doubt  accounted  for  b}^  the  fact  that  the  colon  at  the  spot  where 
it  has  been  drawn  into  the  Avound,  owing  to  the  shallowness  of  the 
loin  or  the  length  of  the  meso-colon,  is  scarcely  kinked  or  bent  at  all ; 
this  leads  to  escape  of  faces  over  the  malignant  growth  and  much 
pain  and  teasing  diarrhoea.  (2)  To  persistence  of  the  growth  in  the 
bowel  below,  causing  a  profuse  sanious  discharge.  (3)  To  the  growth 
extending  upwards  towards  the  wound,  or  to  the  bowel  having  been 
opened  only  just  above  the  growth. 

As  a  rule,  the  more  complete  the  failure  of  previous  treatment,  the 
more  painful,  difficult,  frequent,  and  unsatisfactory  the  action  of  the 
bowels,  the  greater  the  tendency  of  distension  of  the  sigmoid  or  lower 
intestines  generally,  the  more  frequent  the  attacks  of  gripings  and 
partial  obstructions,  which  herald  in  the  tormina  of  a  complete 
miserere;  the  younger  the  patient,  and  thus  the  longer  the  natural 
prospect  of  active  life,  the  more  plain  are  the  indications  for  colotomy. 
On  the  one  hand,  certain  special  evils  *  call  loudly  for  the  relief  which 
the  operation  may  give — viz.,  a  patulous  or  invaded  sphincter  allow- 
ing of  involuntary  escape  of  flatus  and  faeces,  multiple  fistulse  giving 
rise  to  foul  sanious  discharge,  keeping  the  patient  (perhaps  a  woman 
of  scrupulous  cleanliness)  in  a  constantly  filthy  condition,  and  lead- 
ing to  a  brawny,  painful  condition  of  the  buttocks,  which  thus  readily 
become  the  seat  of  cellulitis  and  its  allies ;  i^rojection  of  the  growth 

*  To  quote  only  two  sjiecial  wretchednesses — e.g.,  when  a  lady  cannot  rise  from  her 
easy-chair  without  an  esca|:e  of  flatus  or  faeces  taking  place  from  a  powerless  sphincter, 
or  when  a  man  is  threatened  with  agonies  of  pain  from  the  carcinoma  eating  back- 
wards and  involving  the  sacral  nerves,  and  causing  caries  of  the  sacrum,  with  fistulse 
and  fold  discharge. 


LUMBAR   COLOTOMY.  593 

downwards  through  the  anus,  leading  not  onl}''  to  a  patulous  sphincter 
and  its  consequent  wretchedness,  hut  also  to  irksome  or  painful  sitting. 
On  the  other  hand,  certain  conditions  contraindicate  the  operation 
— viz.,  exhaustion  of  strength,  evidence  of  secondary  deposits  in  the 
peritoneal  cavity,  liver,  lungs,  or  pleura ,  absence  of  much  pain  or 
obstruction  from  first  to  last, 

(3)  Annular  stricture  of  the  sigmoid  colon. 

(4)  Malignant  disease  of  the  large  intestine  higher  uj) — viz.,  in  the 
splenic  or  hepatic  flexures. 

(5)  Pelvic  tumors  pressing  on  the  rectum. 

(6)  Results  of  pelvic  cellulitis  narrowing  the  rectum. 

(7)  Chronic  intestinal  obstruction  due  to  any  of  the  above  causes. 

(8)  Vesico-intestinal  fistula. 

Lumbar  colotomy  is  j)erformed  in  cases  of  communication  between 
the  large  intestine,  esi^ecially  the  rectum,  and  the  bladder,  to  prevent 
the  passage  of  fseces  into  the  bladder,  with  its  results  of  cystitis,  ago- 
nizing obstruction  of  urine,  and  passage  of  flatus  from  the  urethra 
without  notice  and  beyond  control. 

Such  a  fistula  is  much  more  frequently  met  with  between  the  sig- 
moid or  rectum  and  the  bladder ;  if  between  the  latter  and  the  rectum 
the  communication  may  be  found  by  the  finger,  or  by  passing  a  duck- 
bill speculum  and  injecting  colored  fluids.*  Too  frequently  malignant 
in  character,  it  is  occasionally  of  a  simpler  nature — e.g.,  dysenteric, 
etc.,  and  so,  perhaps,  curable.  Thus,  in  Mr.  Holmes's  case  (Med.  Chir. 
Trans.,  vols.  xlix.  and  1.)  the  ulceration  between  the  sigmoid  and  the 
bladder  was  not  malignant,  colotom_y  for  fifteen  months  was  most 
successful,  but  a  permanent  cure  was  prevented  by  similar  ulceration 
taking  place  between  the  caecum  and  bladder  which  caused  death. 
Whether  the  cause  is  malignant  disease  or  no,  the  life  which  lies  before 
the  patient  is  scarcely  tolerable. 

The  opening  is  far  more  frequentlv  valvular  in  nature — i.e.,  while  it 
admits  of  the  passage  of  fa?ces  into  the  bladder,  urine  very  rarely  passes 
per  anum. 

Site  of  the  Proposed  Colotomy. — In  some  cases,  especially 
where  intestinal  oljstruction  is  threatening  from  malignant  disease,  the 
surgeon  ma}^  be  in  doubt  as  to  tlie  site  of  the  disease,  and  therefore  on 
which  side  to  operate.  It  is  quite  impossible  to  make  fixed  rules  for 
advice,  but  the  following  will  help  in  doubtful  cases : 

(1)  The  proportionate  frequency  of  stricture  in  different  parts  of  the  large 

*  The  following  plan,  based  upon  one  made  use  of  by  Mr.  Lnnd  [Hvnt.  Led.  1885, 
p.  91),  would  very  likely  be  useful — viz  ,  to  pass  into  the  rectum  a  bougie  round  which 
is  wound  a  strip  of  Hut  well  soaked  in  starch  and  water  and  dried,  and  then  to  inject  into 
the  bladder  some  diluted  iodine  solutiuu.  A  j-tain  of  starch  iodide  on  tiie  bougie  would 
show  the  position  of  the  fistula. 

38 


594  OPERATIONS  ON  THE  ABDOMEN. 

intestine.  The  frequency  of  disease  in  the  rectum  and  sigmoid  flexure, 
as  compared  with  any  other  part  of  the  large  intestine,  and,  generally 
speaking,  the  frequency  of  disease  in  the  left  side  of  the  arch  formed 
by  the  large  intestine,  as  compared  with  such  disease  in  the  right  side, 
are  well  known.* 

(2)  The  Use  of  Large  Injections. — Dr.  Fagge  {loc.  supra  cit.,  p.  318), 
thus  writes  on  this  subject:  " Several  writers,  and  especially  the  late 
Dr.  Brinton,  have  laid  stress  on  the  value  of  large  injections  as  an  aid 
to  diagnosis.  The  observer  I  have  named  has  even  laid  down  definite 
rules  for  our  guidance  in  this  respect.  '  It  is  quite  singular,'  he  says, 
'  how  trustworthy  I  have  found  the  conclusions  thus  arrived  at.  For 
example,  with  a  maximum  injection  of  a  pint  of  warm,  bland  liquid, 
the  obstruction  in  an  ordinary  male  adult  may  be  referred  to  a  point 
not  lower  than  the  upper  third  of  the  rectum.  A  pint  and  a  half,  two 
pints,  three  pints,  belong  to  corresponding  segments  of  the  sigmoid 
flexure.  The  descending  and  transverse  colon  accept  a  larger,  but  more 
irregular,  quantity.  In  one  case,  in  which  it  was  evident  that  the 
stricture  occupied  the  upper  part  of  the  ascending  colon,  nine  pints  of 
injection  were  always  found  to  be  the  maximum.'"  Dr.  Fagge  points 
out  that  the  correct  determination  of  this  point  requires  much  care,  as 
(a)  some  of  the  fluid  measured  may  escape  in  the  injection;  and  (6) 
a  stricture  may  be  pervious  to  fluid  injected  from  beloAV,  though  the 
intestinal  contents  may  be  unable  to  pass  through  it  from  above. 
Thus,  in  a  case  in  which  there  was  a  mass  of  disease  in  the  sigmoid 
flexure,  just  above  the  pelvis,  4  pints  of  water  were  injected  per  rectum ; 
of  this  a  small  portion  only  returned,  the  greater  part  passing  through 
the  stricture  and  adding  to  the  accumulations  above  it.  I  would  add 
one  more  caution  with  regard  to  these  injections.  Patients,  in  much 
misery,  and  having  submitted  to  one  or  two  rectal  examinations,  will 
sometimes  ask  for  an  ancesthetic.  Such  an  aid  must  be  used  with  great 
caution  if  there  is  already  abdominal  distension.  There  is  not  only  a 
danger  of  adding  seriously  to  the  distension,  and  thus  further  weak- 
ening or  rupturing  parts  which  may  be  already  near  the  point  at  which 
they  give  way — e.g.,  a  caecum  with  "  distension  ulcers  " — but  an  antes- 
thetic,  especially  chloroform,  has  additional  dangers  in  such  cases  as 
these,  where,  in  a  patient  probably  no  longer  young,  the  action  of  the 
heart  and  lungs  are  interfered  with  by  the  upward  pressure  against 
the  diaphragm, 

(3)  The  distance  to  ivhich  a  long  bougie  or  rectal  tube  passes  is  of  very 
little  value,  and  needs  only  the  briefest  mention  here,  because  the  sur- 

*  Dr.  Fagge,  in  drawing  attention  to  this  fact  {Guy's  Hosp.  Reports,  1868,  p.  314), 
quoted  the  following  statistics  from  Dr.  Brinton  :  "Of  100  cases,  4  are  in  the  Cfecum, 
10  in  the  ascending  colon,  11  in  the  transverse  colon,  14  in  the  descending  colon,  30 
in  the  sigmoid  flexure,  and  30  in  the  rectum."  The  statistics  of  Dr.  Fagge  and  M. 
Duchaussoy  confirm  the  above. 


LUMBAR   COLOTOMY.  595 

geon  is  still  called  to  cases  in  which  he  is  assured  that  the  obstruction 
cannot  be  in  the  rectum  or  low  down  in  the  sigmoid  flexure,  as  a  long 
bougie  has  been  easily  passed  its  full  length.  This  fallacy,  which  is 
due  to  the  bougie  bending  on  itself,  is  more  frequent  than  the  other 
one,  in  which  the  arrest  of  a  bougie  by  one  of  Houston's  folds  misleads 
into  the  belief  that  a  stricture  exists  low  down. 

(4)  The  form  of  the  abdomen  may  give  valuable  conclusions.  Thus 
Dr.  Fagge  {he.  supra  cit.,  p.  319),  gives  a  case  of  cancer  of  the  hepatic 
flexure,  in  which  it  was  observed  during  life  that  the  cajcum  and 
ascending  colon  were  distended,  and  not  the  descending  colon.  Again, 
he  observes  that  when  the  rectum  or  the  sigmoid  flexure  is  the  seat  of 
obstruction,  the  lumbar  regions  and  the  epigastrium  are  no  doubt 
generally  prominent,  and  the  course  of  the  colon  is  more  or  less 
plainly  marked  out.  That  these  conclusions  are  only  valuable  if  not 
too  implicitly  relied  upon,  is  shown  by  the  fact  that  cancer  of  the 
rectum  may  be  present,  with  vomiting,  peristalsis,  and  borborygmus, 
and  yet  there  may  be  no  general  distension  of  the  abdomen,  no  filling 
out  at  all  of  its  sides:  on  the  other  hand,  a  prominent  epigastrium 
and  the  appearance  of  a  large  horizontal  coil  of  intestine  here  may  lead 
to  the  conclusion  that  the  transverse  colon  is  distended,  the  disease 
being,  nevertheless,  in  the  ilium,  a  distended  coil  of  which  has  rivalled 
the  colon  itself. 

(5)  A  symptom  of  some  value,  if  verified  by  the  medical  man 
himself,  is  the  fact  that  for  some  time  the  motions  have  Ijeen  narrow, 
tape-like,  broken  up,  abnormal  in  bulk,  shape,  and  length.  Certain  fallacies 
diminish,  however,  the  value  of  the  above — e.g.,  that  in  cases  of 
stricture  high  up,  as  in  the  upper  part  of  the  sigmoid  flexure,  there  is 
probably  room  for  the  fteces,  after  they  have  got  through  the  stricture, 
to  collect,  till  their  characteristic  form  is  given  them,  though  we  do  not 
know  how  far  irritation  of  the  intestine  and  formation  of  mucus  at  the 
seat  of  the  growth  may  interfere  with  this. 

(6)  A  few  other  points — e.g.,  constant  arrest  of  borborygmi  at  one  spot, 
Jixedpain  at  oneplace,  as  in  the  right  hypochondrium — may  give  useful 
indications,  while  others,  such  as  n,  rectal  examination,  are  so  obvious  as 
scarcely  to  deserve  mention. 

If,  after  weighing  the  above,  the  surgeon  is  still  in  doubt  as  to  the  exact 
site  of  the  disease  of  the  large  intestine,  he  should  not  hesitate  to  j^er- 
form  right-sided  lumbar  colotomy.  He  should  not  be  deterred  from 
this  by  the  anatomical  difficulties^  supposed  to  exist  on  this  side. 
Especially  where  the  colon  is  at  all  thickened  or  distended,  the  opera- 
tion on  one  side  is  no  more  difficult  than  on  the  other. 

*  Eg ,  a  more  complete  peritoneal  coat. 


596  OPEEATIONS    OX   THE    ABDOMEX. 

Some  Points  in  the  Surgical  Anatomy  of  Colotomy,  and 
Landmarks  Useful  in  the  Operation.— The  i)arts  cut  through, 
and  the  means  of  recognizing  the  colon,  are  fully  given  below.  Atten- 
tion will  here  be  drawn  to  the  connection  of  the  peritoneum  with  the 
colon,  and  on  this  point  we  have  nothing  more  accurate  than  the  ob- 
servations of  Braune.*  This  anatomist  writes  :  "  It  is  usually  stated 
that  the  descending  colon  lies  along  the  outer  border  of  the  quadratus. 
....  This  is  not  always  correct.  At  the  level  of  the  symphysis  be- 
tween the  third  and  fourth  vertebrse,  and  at  the  fourth  below  the 
kidney — and  therefore  exactly  in  the  field  of  operation — the  quadratus 
lumborum  covers  in  the  colon  posteriorly,  and  must  be  cut  in  order 
to  reach  it.  It  is  only  when  much  distended,  a  condition  which  is  not 
so  constant  as  one  Avould  expect  in  operations,t  that  the  intestine  in- 
creases in  breadth  forwards  and  inwards,  or  overlaps  the  outer  border 
of  the  muscle."  Professor  Braune  goes  on  to  say  that,  from  the  im- 
possibility of  recognizing  the  peritoneum  from  its  posterior  aspect, 
success  can  only  be  safely  calculated  on  by  measuring  the  distance  of 
the  point  of  reflection  of  the  peritoneum,  and  how  far  from  the  colon 
this  position  is  constant.  "As  regards  the  descending  colon,  which  I 
here  joarticularly  refer  to  after  measurements  of  frozen  bodies  of  full- 
grown  men,  I  find  that  this  distance,  in  a  straight  line  (therefore  not 
corresponding  with  the  curvature  of  the  wall  of  the  intestine),  is  from 
four-fifths  of  an  inch  to  an  inch,  supposing  the  intestine  empty  and 
contracted  (at  a  level  between  the  third  and  fourth  lumbar  vertebrse)  ; 
further,  that  the  free  side  of  the  intestine  does  not  look  posteriorly, 
but  somewhat  inwards,  exactly  towards  the  angle  which  the  psoas  and 
quadratus  make  with  each  other.  If,  on  the  other  hand,  the  small 
intestines  are  much  distended,  ....  the  colon,  by  means  of  the 
traction  of  the  parietal  peritoneum,  would  be  rotated  on  its  axis,  so 
that  its  free  surface  would  be  directed  more  outwards. 

"  Should  the  colon  itself  be  distended,  its  surface,  free  of  peri- 
toneum, Ijecomes  considerably  larger,  and  may  assume  a  breadth  of 
from  2  to  2.5  inches." 

It  is  beyond  doubt  that  the  surface  free  from  peritoneum  is  less 
extensive  on  the  right  than  on  the  left  side,  and  that  a  meso-colon  is 
more  frequently  met  with  in  the  case  of  the  ascending  than  in  that  of 
the  descending  colon.  The  former  fact  will  not  cause  trouble  when 
the  colon  is  distended ;  the  layers  of  the  meso-colon,  if  identified, 
might  be  parted  from  each  other,  but  the  safest  way  of  meeting  these 
complications  is  to  perform  the  operation,  whenever  possible,  in  two 

*  Atlas  of  Topographical  Anatomy  (translated  by  Mr.  Bellamy),  p.  133. 

t  Thus  in  Fig.  2  (Pirogoff),  p.  131,  of  Prof.  Braune's  book,  where  the  intestines  are 
shown  much  inflated  with  air,  the  ascending  colon  is  well  distended,  the  descending 
somewhat  collapsed. 


LUMBAR    COLOTOMY.  597 

stages,  and  on  all  occasions  to  adopt  the  most  stringent  antiseptic 
precautions  possible. 
Landmarks  (Fig.  101). 

1.  The  lower  border  and  tip  of  the  last  rib. 

2.  A  point  *  inch  behind  the  centre  of  the  crest  of  the  ilium,  this 
point  being  found  by  accurate  measurement  along  the  crest  between 
the  anterior  and  posterior  superior  spines  (Allingham). 

3.  A  line  drawn  vertically  up  from  the  last-mentioned  point  to  the 
last  rib.  This  gives,  with  sufficient  correctness,  the  line  of  the  outer 
edge  of  the  quadratus,  and  the  position  of  a  normal  colon. 

Owing  to  the  varying  length  of  the  last  rib,  the  upper  end  of  this 
line  may  meet  this  bone  at  its  tip,  or  at  a  spot  a  varyiiig  distance  in 
front  of  or  behind  this  point.  It  is  well  to  dot  the  ends  of  this  ver- 
tical line  with  an  aniline  pencil.  The  dent  of  a  finger-nail,  made 
when  the  patient  has  been  brought  under  the  anaesthetic,  will  mark 
these  points  sufficiently  to  begin  with,  but  a  little  later,  in  a  difficult 
case,  the  surgeon  may  be  glad  of  having  taken  ever}'-  possible  pre- 
caution. 

Incisions. 

1.  Vertical,  of  Callisen.  This  at  first  sight  is  the  best,  as  it  follows 
the  above  line,  and  thus  corresponds  anatomically  to  the  colon,  but  it 
has  the  disadvantage  of  giving  but  limited  space,  especially  in  a  fat 
or  deep-chested  patient ;  and  if  prolonged  upwards,  so  as  to  give  all 
the  space  possible,  it  divides  the  intercostal  vessels  running  with  the 
last  dorsal  nerve,  and  gives  rise  to  troublesome  haemorrhage. 

2.  Transverse,  of  Amussat. 

3.  Oblique,  of  Bryant,  modified  from  the  above.  One  of  the  two 
latter  is  usually  employed;  they  have  the  great  advantage  of  being 
readily  prolonged  when  more  room  is  required,  and  the  oblique 
incision  corresponds  better  with  the  course  of  the  nerves  and  vessels.* 

It  is  the  one  given  below. 

Operation  cFigs.  101, 102). 

The  patient  being  turned  on  to  his  side  (most  usually  the  right) 
with  a  firm  pillow  under  the  loin,  the  parts  cleansed,  the  tija  of  the 
last  rib  and  the  point  on  the  crest  of  the  ilium,  as  given  above,  being 
dotted  with  an  aniline  pencil,  an  incision  is  made,  beginning  2*  or  3 
inches  from  the  spine,  according  to  the  size  of  the  erector  spine,  a 
little  below  the  last  rib,  and  running  downwards  and  forwards  for 

*  Mr.  Greig  Smith  (Abdom.  Surg.,p.S96)  thinks  that  this  incision  helps  to  prevent 
prolapse  of  the  bowel  by  lying  almost  trans%'erse  to  its  axis.  He  gives  also  the  follow- 
ing practical  hint :  "  In  thin  patients,  and  particularly  in  women,  whose  iliac  crests 
are  more  prominent  than  in  men,  there  is  a  tendency  for  the  upper  lip  of  the  wound 
to  fall  inwards,  while  the  lower  lip  protrudes.  This  may  be  obviated  by  careful  appo- 
sition, and  by  not  bringing  the  line  of  the  incision  too  close  to  the  ilium."^ 


598 


OPERATIONS  ON  THE  ABDOMEN. 


3  J  to  4  inches  towards  the  anterior  superior  spine.  The  centre  of  this 
incision  should  bisect  the  line  given  at  p.  597  as  the  line  of  the  colon. 
The  first  cut  should  expose  the  muscles,  the  skin  in  the  posterior 
half  being  thick,  and  the  subcutaneous  fat  often  abundant.  The 
next  may  go  well  into  the  muscles,  the  remainder  of  which  should 
be  then  carefully  divided  with  the  knife,  or  torn  through  with  a 
steel  director,  so  as  to  expose  the  fascia  lumborum ;  any  bleeding 
vessels  being  now  secured,  this  fascia  is  pinched  up,  nicked  and  slit 
upon  a  director.  Two  retractors  being  placed  on  the  lips  of  the 
wound,  the  fat  which  lies  around  the  kidney  and  behind  the  fascia 
lumborum  is  next  torn  through  with  two  pairs  of  dissecting  forceps. 
If  the  bowel  is  distended  it  will  bulge  up  into  the  wound,  pushing 
before  it  the  transversalis  fascia,  and  the  operation  can  be  readily 
completed.     If,  on  the  other  hand,  the  bowel  is  empty,  the  real  diffi- 

FiG.  101. 


culties  of  the  operation  only  begin  at  this  stage.  The  wound  being 
well  opened,  the  kidney,  if  it  come  down  below  the  rib  (as  it  occa- 
sionally does,  especially  in  a  patient  breathing  heavily  under  the 
influence  of  an  anesthetic),  being  kept  out  of  the  way  by  the  finger 
of  an  assistant,  the  intestine  is  sought  for  by  scratching  with  a  di- 
rector, or  two  pairs  of  forceps,  through  the  transversalis  fascia  (Fig. 
101)  exactly  in  the  line  to  which  attention  has  been  already  drawn. 
Several  layers  of  cellular  tissue  may  be  met  with  here,  and  it  is  now 
that  most  of  the  difficulty  is  usually  met  with,  owing  to  the  operator 
being  afraid  of  the  peritoneum,  and  to  his  not  opening  the  trans- 
versalis fascia  with  sufficient  decision. 

When  this  has  been  done,  scybala  in  the  colon  will  in  many  cases 
be  felt,  but  if  the  large  intestine  is  empty  much  trouble  may  be  met 


LUMBAR   COLOTOMY.  599 

with  in  detecting  it  and  getting  it  up  into  the  wound,  especially  if, 
close  by,  the  peritoneum  is  bulging  up. 
At  this  stage  the  following  points  may  be  usefully  remembered : 

(a)  The  exact  position  of  the  line  of  the  colon  (pp.  596,  597). 

(b)  The  lower  end  of  the  kidney,  and  its  relation  to  the  colon. 

(c)  The  outer  edge  of  the  quadratus  lumborum  (p.  596). 

(d)  The  sensation  of  thickness  as  given  to  the  fingers  in  pinching 
up  the  colon,  thus  distinguishing  large  from  small  intestine. 

(g)  The  feel  of  scybala  if  present. 

(/)  Seeing  one  of  the  three  longitudinal  muscular  bands  which  dis- 
tinguish the  colon.* 

ig)  Inflation  with  air  or  injection  of  fluid. f 

(h)  Mr.  Bryant  has  advised  rolling  the  patient  over  on  to  his  face 
at  this  stage,  so  that  the  colon  may  be  felt  to  fall  on  the  finger  inserted 
deep  into  the  wound. 

The  bowel  having  been  found,  its  posterior  surface  is  to  be  drawn 
well  up  into  the  wound,  and  if  the  case  is  not  an  urgent  one,  retained 

Fig.  102. 


Colotomy  in  two  stages.    The  bowel  is  shown  secured  with  pins  at  the  close  of  the  first  stage. 

there  by  passing  long  hare-lip  pins  through  it.     There  is  no  need  to 
pass  the  pins  through  the  edges  of  the  wound ;  they  simply  lie  across 

*  Mr.  H.  Allingham  {Brit.  Med.  Journ.,  April  28,  1888)  seems  to  consider  it  very 
difficult  to  ensure  finding  one  of  these  bands  without  opening  the  peritoneal  cavity. 
While  I  should  he  the  last  to  make  light  of  the  difficulties  which  may  beset  this 
operation,  I  feel  sure  that  few  surgeons,  who  have  had  a  large  experience  of  colotomy, 
will  agree  that  the  above  step  is  needful,  especially  if  the  line  given  by  Mr.  Allingham's 
father  be  strictly  followed. 

f  Air  is  most  readily  made  use  of.  It  may  be  pumped  in  by  a  Higgenson's  syringe, 
a  Lister's  hand-spray,  but,  best  of  all,  by  the  special  apparatus  described  by  Mr.  Lund 
{Lancet,  1883,  vol.  i.  p.  588),  which,  by  means  of  an  elastic  ring,  secures  air-tight 
contact  with  the  anus  while  air  is  being  pumped  in,  either  as  an  aid  in  colotomy,  or 
as  a  means  of  reducing  an  intussusception.  In  some  cases  of  cancerous  disease  of  the 
rectum  it  will  be  very  difficult  to  introduce  any  nozzle  for  inflation  beyond  the  disease. 
In  the  summer  of  1885,  when  performing  colotomy  at  Guy's  Hospital  in  a  patient, 
the  lower  part  of  whose  rectum  had  been  unsuccessfully  excised  at  another  hospital,  I 
found  it  impossible  to  introduce  any  nozzle  when  desirous  of  inflating  an  empty  colon. 


600  OPERATIONS  ON  THE  ABDOMEN. 

these,  resting  on  the  margins  of  the  wound  at  either  side,  a  few  strips 
of  iodoform  gauze  being  placed  under  them,  or  little  slips  of  cork  on 
their  ends.  The  pins  should  be  passed  through  the  bowel  at  a  dis- 
tance of  at  least  f  inch  from  each  other,  so  as  to  render  easy  the 
opening  of  the  bowel  in  a  few  days'  time,  and  they  should  not,  if  it 
can  be  managed,  penetrate  all  the  coats  of  the  intestine.  The  pins 
are  so  fine*  that  any  puncture  of  the  canal  itself  will  probably  give 
rise  only  to  a  little  flatus,  readily  met  with  iodoform.  The  mtirgins 
of  the  wound  are  then  carefully  closed  with  silver  wire  or  carbolized 
silk  sutures,  and  a  few  fine  ones  may  be  passed  between  the  bowel 
itself  and  the  margins  of  the  wound.  Dry  gauze  dressings  are  then 
applied,  iodoform  being  dusted  over  the  bowel  and  wound.  These 
dressings  will  probably  not  need  changing  till  the  fourth  day,  when 
the  operation  is  completed  by  opening  the  bowel  with  a  tenotomy 
knife  between  the  pins';  this  opening  may  be  a  small  crucial  one, 
very  little  but  flatus  will  pass  at  the  time,  but  a  director  will  show  the 
presence  of  fseces,  and  mild  aperients  may  be  given  as  soon  as  the 
parts  are  firmly  healed.  The  above  raethod  of  performing  colo- 
tomy  by  two  stages  was  introduced  at  Guy's  by  some  of  my 
senior  colleagues,  Mr.  Bryant,  Mr.  Howse,  and  Mr.  Davies-CoUey, 
being  based  on  that  most  important  modification  of  gastrostomy 
which  Mr.  Howse  was  the  first  to  make  use  of  in  this  country.  Mr. 
Davies-Colley  brought  before  the  Clinical  Society  (Trans.,  vol.  xviii. 
1885,  p.  204)  a  paper  on  "  Three  Cases  of  Colotomy  with  Delayed 
Opening  of  the  Intestine."  It  was  from  him  I  learnt  the  use  of  the 
pins  t  given  above.  Some  operators  —  viz.,  Mr.  Bryant  and  Mr. 
Howse — have  had  good  results  after  simply  drawing  out  the  knuckle 
and  leaving  it  protruding  in  the  wound  without  any  sutures  to  secure 
it,  or  fixed  with  torsion  forceps,  the  blades  covered  with  drainage- 
tube,  applied  with  just  sufficient  force  to  hold  up  the  intestine  without 
causing  sloughing.  To  apply  the  right  degree  of  pressure  is  a  matter 
of  some  difficulty,  and  with  regard  to  the  method  of  leaving  a  knuckle 
without  sutures,  I  agree  with  Mr.  Davies-Colley  (loc.  sivpra  clL,  p.  209) 
that  serious  difficulties  may  arise  from  the  bowel  slipping  back  into 
the  wound.;};     This  is  especially  likely  to  occur  in  a  restless  patient, 

*  A  good  form  of  pin  is  mentioned  in  footnote  following. 

t  In  six  cases  of  colotomy  which  I  performed  in  1887,  I  used  some  pins  made  for 
me  by  Messrs.  Downs.  Their  steel  is  sufficiently  tempered  to  be  slightly  flexile, 
thus  yielding  a  little,  a  point  of  much  importance  when  the  knuckle  of  the  colon  has 
to  be  dragged  up  to  the  surface  of  a  very  fat  loin,  and  thus  exerts  much  tension  on 
the  pins.  The  flat  heads  rest  comfortably  on  the  skin  margins  of  the  wound,  without 
causing  any  ulceration. 

X  In  one  case  which  was  under  my  care  two  years  ago,  in  which,  after  drawing  out 
a  knuckle  of  sufficient  size,  I  had  been  content  to  fix  it  with  numerous  very  fine  silk 


LUMBAR    COLOTOMY.  601 

in  cases  wliere  the  wound  is  very  deep,  and  where,  owing  to  the  pa- 
tient's weakly  condition  or  from  suppuration  taking  place,  the  intes- 
tine does  not  early  become  firmly  fixed.  The  great  advantage  of  this 
two-stage  method  is  that  it  defers  the  opening  of  the  bowel  till  this 
is  sufficiently  adherent.  (2)  By  this  delayed  escape  of  intestinal 
contents  the  gravity  of  any  injury  to  the  peritoneum  at  the  time  of 
the  operation  is  very  much  diminished.  (3)  The  second  great  trouble 
after  colotomy,  that  of  burrowing  suppuration  up  and  down  the 
planes  of  cellular  tissue,  which  have,  of  necessity,  been  freely  opened, 
is  done  away  with.  The  opening  of  the  intestine  being  delayed,  pri- 
mary union  to  a  very  large  extent  can  be  secured,  especially  with  the 
aid  of  deeply  passed  sutures,  or  of  chromic  gut  ones  cut  short  and 
dropped  in,  and  dry  dressings. 

If  it  is  necessary  to  complete  the  operation  at  one  stage  the  bowel 
should  be  drawn  up  into  the  wound  as  much  as  is  possible,  and  a  few 
silk  stitches  inserted  so  as  to  shut  off  the  surrounding  cellular  tissue 
planes  from  the  escaping  faces.  The  bowel  may  then  be  opened  by 
an  incision  f  inch  long,  and  these  cut  edges  also  stitched  to  the  mar- 
gins of  the  wound.  The  rest  of  the  wound  is  then  closed  as  accurately 
as  possible,  the  parts  around  the  wound  freely  smeared  with  euca- 
lyptus and  vaseline,  the  wound  dressed  with  this  or  carbolic  oil,  and 
a  pad  of  carbolized  tow,  and  the  dressings  kept  in  position  by  a  many- 
tailed  bandage,  by  which  means  they  are  readily  and  painlessly 
renewed. 

If  the  bowel  is  too  tense  to  allow  of  its  being  stitched  in  situ  before 
it  is  opened,  it  may  be  secured  by  passing  a  ligature  first  through  one 
lip  of  the  wound,  then  across  the  bowel  and  through  the  opposite  lip, 
and  another  in  the  same  way  about  i  inch  from  the  first,  an  incision 
4  inch  long  is  then  made  into  the  gut,  over  these  sutures,  their  centre 
hooked  up  into  the  wound,  and  the  four  halves  tied  on  either  side, 
a  few  other  sutures  being  put  in  between  the  cut  bowel  and  the  wound. 
If  the  bowel  is  much  distended  there  is  always  some  risk  of  faecal 
matter  being  forced  into  the  different  planes  of  cellular  tissue,  unless 
every  precaution  is  taken  to  keep  the  knuckle  well  up,  and  to  close 
the  wound  thoroughly  around  it. 

If  the  bowel  is  full  of  hard  scybala  no  attempt  should  be  made  to 
remove  them ;  they  may  be  left  for  a  day  or  two  till  aperients  can  be 
given.  At  times  the  bowel  seems  so  empty  as  to  suggest  a  failed 
operation  ;  there  is  no  occasion  to  be  troubled  at  this ;  the  contents 
will  pass  shortly. 

sutures,  the  bowel  was  found,  on  the  third  day,  when  the  wound  was  dressed,  to  have 
slipped  deeply  back,  owing  to  the  above  fine  sutures  cutting  through,  and  very  great 
difficulty  was  met  with  in  completing  tlie  operation.  The  wound  had  here  united 
without  suppuration,  but  the  patient  was  most  restless. 


602  OPERATIONS  ON  THE  ABDOMEN. 

Difficulties  in  Colotomy. 

1.  An  empty  bowel.*    This  has  been  already  alluded  to  (p.  599). 

2.  Mistaking  bulging  peritoneum  for  colon  and  opening  it.  This 
may  be  due  to  the  surgeon  forgetting  the  line  of  the  bowel,  and  work- 
ing deeply,  too  far  forwards  ;  or  it  may  take  place  from  no  fault  of  the 
surgeon,  being  due  to  the  presence  of  a  meso-colon,  or  to  the  ex- 
tremely contracted  condition  of  the  colon. f  It  by  no  means  always 
causes  peritonitis.  When  this  accident  has  happened,  as  shown  by 
the  escape  of  a  little  serous  fluid,  the  appearance  of  a  coil  of  small 
intestine  or  of  omentum,  the  oi:)ening  should  be  at  once  taken  up  with 
dissecting-forceps  and  tied  round  Avith  carbolized  silk  or  chromic  gut, 
and  a  little  iodoform  dusted  round  the  opening. 

3.  A  very  fat  loin.  This  is  not  a  very  uncommon  source  of  diffi- 
culty in  elderly  people  who  require  colotomy.  It  must  be  met  by  a 
very  free  incision  in  which  all  the  tissues  are  cut  equally  throughout 
(i.e.,  not  making  a  conical  wound  deep  only  in  its  very  centre).  It 
not  only  adds  to  the  difficulty  of  finding  the  bowel,  but  also  of  retain- 
ing it  in  situ  afterwards.  To  meet  the  additional  tension  and  tendency 
of  the  gut  to  drag  away  in  these  cases,  it  must  be  more  carefully 
secured  by  close  stitching,  especially  if  it  is  necessary  to  do  the  oper- 
ation in  one  stage,  every  care  being  taken  to  prevent  extravasation  of 
faeces  into  the  surrounding  cellular  tissue. |    In  fat  people  the  surgeon 

*  It  is  noteworthy  that  the  intestine  may  be  found  empty,  even  in  obstructions  of 
long  continuance.  Thus,  Mr.  Curling  {Diseases  of  the  Rectum,  p.  182)  writes:  "In  a 
case  of  carcinomatous  stricture  of  the  rectum,  in  which  I  performed  colotomy,  after  a 
month's  obstruction,  in  a  woman  aged  forty,  not  only  was  the  colon  contracted,  but  it 
was  actually  compressed  against  the  spine,  and  put  out  of  the  way  by  the  distended 
small  intestine,  so  that  it  was  impossible  to  reach  the  bowel  without  opening  the  peri- 
toneum. No  inflammation  or  unfavorable  symptoms  resulted."  It  would  have  been 
interesting  to  know  whether  more  than  one  obstruction  did  not  exist  in  the  large 
intestine  in  this  case. 

t  In  a  case  in  which,  owing  to  the  extreme  pain  during  defecation,  the  patient  had 
dreaded  any  action  of  the  bowels,  and  had  eaten  very  little,  the  colon  was  much  con- 
tracted and  lay  far  back.  In  trying  to  find  it,  I  opened  the  peritoneum,  and  omentum 
protruded.  A  carbolized  sponge  was  kept  over  the  opening  while  the  colon  was  found, 
the  opening  then  tied  up  with  chromic  gut,  and  the  colon  not  opened  for  four  days. 
No  ill  result  followed.  As  in  supra-pubic  lithotomy,  the  peritoneum  may  give  way 
during  vomiting.  Thus  Dr.  Walters  {Brit.  Med.  Journ.,  1879,  vol.  i.  p.  212)  was 
stitching  the  colon  to  the  wound  when  "  the  patient  retched  violently,  causing  the  peri- 
toneum to  give  way  and  a  coil  of  intestine  to  protrude  from  the  anterior  part  of  the 
wound.  This  was  immediately  covered  with  warm  sponges,  cleansed  from  the  feculent 
matter  it  had  acquired  by  contact  with  the  open  colon,  and  returned."  When,  five 
weeks  later,  the  patient  sank  from  exhaustion,  no  trace  of  peritonitis  was  found  at  the 
post-mortem  examination. 

X  As  much  of  the  wound  as  is  possible  should  be  closed  before  the  intestine  is 
opened. 


LUMBAR  COLOTOMY.  603 

must  be  prepared,  not  only  for  much  subcutaneous  but  for  abundant 
extra-peritoneal  fat  also,  coarse,  and  difficult  to  dissect  in.  If,  in 
such  a  case,  the  colon  is  contracted,  there  are  few  more  difficult 
operations. 

4.  Presence  of  a  meso-colon.  This  may  be  a  cause  of  much  difficulty 
and  doubt,  and  render  opening  of  the  peritoneum  necessary.  Where 
this  is  the  case,  the  surgeon  should  ahvays  defer  opening  the  colon  if 
possible.  Mr.  Jessop  (Brit.  Med.  Joitrn.^  1879,  ii.  614)  mentions  cases 
in  which,  owing  to  the  presence  of  the  above,  he  wag  obliged  to  open 
the  peritoneal  cavity  and  incise  the  gut  through  its  peritoneal  coat. 
The  cut  edges  of  the  bowel,  brought  through  the  opening  in  the  peri- 
toneum, were  stitched  to  the  skin  as  in  the  ordinary  operation.  No 
bad  effect  followed.  Mr.  Bennet  May  {Brit.  Med.  Journ.,  1882,  i.  940), 
operating  on  the  right  side,  found  an  empty  colon,  "  and  it  was  only 
by, keeping  strictly  in  Allingham's  line,  and  patiently  searching  there 
between  the  layers  of  a  great  length  of  meso-colon,  that  the  intestine 
was  reached,  collapsed  and  empty." 

6.  Abnormality  of  colon.  Every  surgeon  must  remember  cases  in 
which  the  descending  colon,  though  present,  was  displaced,  and  came 
down  in  the  middle  line.  Occasionally  part  of  the  large  intestine  is 
actually  absent.  Mr.  Lockwood  {St.  Barthol.  Hosp.  Reports,  xix.  256) 
mentions  three  cases  in  which  the  colon  could  not  be  found  at  opera- 
tions; in  two  its  absence  was  verified  post  mortem,  both  on  the  right 
side.  One  of  these  cases  is  reported  fully.  The  following  are  the 
main  points  :  Owing  to  obstruction  of  the  large  intestine,  the  site  of 
which  was  doubtful,  it  was  decided  to  cut  down  on  the  right  colon. 
No  colon  could  be  found,  and,  relief  being  imperatively  demanded, 
the  peritoneum  was  opened  and  a  looped  small  intestine  drawn  out- 
side the  wound.  Death  occurred  four  hours  after  the  operation,  and 
at  the  autopsy  the  right  colon  was  quite  absent,*  the  cjecum  being 
found  behind  the  liver  in  the  right  hypochondrium,  the  large  intes- 
tine extending  from  this  to  the  splenic  flexure  in  the  usual  manner. 

If  the  colon  cannot  be  found,  three  courses  are  open  to  the  surgeon 
— (a)  To  open  the  small  intestine  through  the  peritoneum  from  the 
colotomy  incision.  The  objections  to  this  step  are  that  it  is  very  fatal, 
and  that  there  is  no  telling  what  part  of  the  small  intestine  is  opened, 
(/?)  To  perform  colotomy  on  the  opposite  side,  and  if  the  colon  is  here 
distended,  to  open  it,  by  two  stages  when  practicable.  This  is  the 
course  that  should  always  be  followed  if  possible,    {y)  If  no  colon  can 

*  Mr.  Lockwood  [Brit,  Med.  Journ.,  1882,  vol,  ii.  p.  574)  explains  the  abnormalities 
of  the  large  intestine  by  the  fiict  that,  during  its  development,  it  is  very  mobile,  the 
CEeeum  occupying  first  the  umbilical,  then  the  left,  next  the  right  hypochondrium, 
and,  finally,  the  right  iliac  region,  abnormalities  following  its  arrest  at  any  part  of  its 
course. 


604  OPERATIONS  ON  THE  ABDOMEN. 

be  found,  or  if  the  part  found  is  below  the  obstruction,  the  linea  alba 
should  be  opened  to  admit  two  fingers  to  explore  for  the  displaced  colon, 
and,  if  no  colon  can  be  found,  to  draw  up  and  attach  a  loop  of  small 
intestine,  chosen  as  near  the  caecum  as  possible.  Or  Nelaton's  opera- 
tion may  be  performed,  this  being  the  wiser  step  if  the  patient  is  ex- 
hausted by  a  previous  prolonged  operation. 

6.  Malignant  disease  at  the  site  of  colotomy.  This  is  best  met  by 
performing  colectomy  in  appropriate  cases,  or  by  performing  coloto- 
my on  the  opposite  side.    • 

Troubles  which  may  be  met  with  after  Colotomy. 

1.  Too  large  an  opening  in  the  bowel.  This  may  lead  to  prolapse 
of  the  mucous  membrane.  If  this  take  place  to  a  large  extent  it  is  a 
great  nuisance  to  the  patient,  owing  to  the  moist,  excoriated,  bleeding 
surface  which  results,  difficult  to  keep  up  by  any  apparatus.  Even 
where  the  opening  has  been  small,  a  good  deal  of  prolapse  may  take 
place  if  there  is  much  cough  and  a  flaccid  condition  of  the  side. 

2.  Too  small  an  opening  ifi  the  bowel.  This  is  of  much  less  moment, 
as  it  can  be  readily  dilated  by  tents,*  Of  these,  laminaria  are  much 
the  most  efficient ;  two  should  be  inserted  at  a  time  to  effect  rapid 
dilatation.  Then  the  opening  is  easily  kept  patent  by  the  occasional 
insertion  of  the  little  finger,  and  by  the  wearing  of  a  proper  plug. 

3.  Teasing  descent  of  scybala  into  the  bowel  below  the  artificial 
anus.  This,  which  often  renders  a  colotomy  disappointing,  is  best 
met  by  bringing  the  colon  sufficiently  into  the  wound  at  first  by  mak- 
ing and  keeping  patent  an  adequate  opening.  If  scybala  still  find 
their  way  down,  the  colon  may  be  washed  out  from  the  anus  or  the 
wound.  If  these  fail,  the  only  course,  and  one  by  no  means  devoid 
of  risk,  is  to  open  up  the  wound,  to  divide  the  bowel,  and  attach  the 
upper  end  in  the  wound,  and  then  to  ligature  the  lower  end  and  drop 
it  in. 

Causes  of  Death  after  Colotomy. 

1.  Peritonitis.  This  may  be  due  to  the  operation  directl}^,  or  more 
indirectly  from  fsecal  or  purulent  retro-peritoneal  extravasation,  or 
from  septicsemia.  Often  it  is  not  due  to  the  operation,  but  to  the  want 
of  it  at  an  earlier  stage.  Thus,  the  distended  bowel  may  have  given 
way  just  above  the  obstruction  ;  often  it  is  that  weak  spot,  the  coecum, 
which  is  found  perforated  after  the  stress  of  distension. f 

*  Tliese  should,  of  course,  be  secured  when  in  situ.  If,  however,  the  surgeon  finds 
that  a  tent  has  accidentally  slipped  into  the  colon,  he  need  not  fear  any  disaster.  This 
accident  happened  in  two  of  my  cases,  owing  to  the  dressers  not  having  taken  efBciert 
steps  to  prevent  it.  One  was  passed  ;  the  other  was  never  heard  of  in  the  year  and 
nine  months  during  which  life  lasted  after  the  operation. 

f  Tlie  following  reasons  have  been  given  in  explanation  of  this  well-known  fact — 
viz,  the  proneness  of  the  caecum  to  give  way  under  the  stress  of  distension,  and  even 


INGUINAL    COLOTOMV.  605 

2.  Extravasation  of  feces  and  burrowing  suppuration.  This  is 
especially  liable  to  happen  in  very  fat  patients,  in  whom  there  is 
difficulty  in  getting  the  colon  well  up  into  the  wound,  especially  if  the 
bowel  must  be  opened  at  once.  As  the  faeces  pump  out  under  high 
pressure,*  a  free  opening  should  in  these  cases  be  made  in  the  bowel 
after  this  has  been  secured  as  carefully  as  possible. 

3.  Exhaustion.  Especially  if  the  operation  has  been  deferred  too 
long. 

4.  Vomiting.  This  has  been  noticed  in  a  few  cases  to  occur  obsti- 
nately and  fatally  after  colotomy.  Mr^  Couper  {Brit.  Med.  Journ., 
1*869,  ii.  557)  thinks  that  it  is  not  an  unfrequent  cause  of  death,  and 
suspects  that  traction  on  the  bowel,  its  proximity  to  the  stomach,  and 
the  fact  that  both  receive  nerves  from  the  solar  plexus,  will  account 
for  this. 

5.  Septic  cellulitis,  erysipelas,  etc. 

6.  Broncho-pneumonia;  pleuritic  effusion,  especially  if  the  wound 
has  become  septic  in  an  exhausted  patient. 

INGUINAL  OR  ANTERIOR  COLOTOMY. 

This,  when  performed  on  the  left  side  for  opening  the  sigmoid 
flexure,  is  known  as  Littre's  operation. 

Indications. 

1.  Inguinal  colotomy  is  usually  performed  on  the  left  side  in  cases 
of  malformation  of  the  rectum,  when  this  part  of  the  intestine  cannot 
be  found  by  a  dissection  in  the  perineum.  It  has  been  disputed  in 
these  cases  whether,  after  an  unsuccessful  exploration  in  the  perineum, 
an  inguinal  or  a  lumbar  colotomy  should  be  performed.  The  great 
majority  of  surgeons  have  preferred  the  former  operation,  following 
here  Mr.  Curling.t  This  surgeon  pointed  out  that  the  lumbar  opera- 
tion was  contraindicated  on  the  following  grounds  :  (a)  the  death-rate 
is  relatively  greater;  (/?)  the  kidney,  varying  in  size  at  this  time  of 
life,  may,  when  large,  overlap  the  colon  ;  (y)  the.colon,  instead  of  being 
distended  with  meconium,  as  might  be  expected,  is  sometimes  con- 
when  at  some  distance  from  the  obstruction.  Dr.  Coupland  and  Mr.  Morris  {Brit.  Med.. 
Journ.,  1878)  attribute  it  to  the  cul-de-sac  nature  of  tliis  part  of  the  intestine  ;  its  fixity  ;. 
dependent  position  ;  its  being  the  place  where  two  currents  meet — viz ,  from  the  ileum, 
and,  in  case  of  regurgitation,  from  the  colon  ;  and  the  pressure  to  which  it  is  subjected 
between  the  iliacus  and  the  abdominal  muscles.  Mr.  Lockwood  {St.  Barthol.  JIosp^ 
Reports,  vol.  xix.  p.  26)  thinks  tliat  the  explanation  lies  rather  in  the  peculiarity  of 
structure  of  the  caecum,  as  it  contains  a  very  large  amount  of  lymphoid  tissue,  and  as  its. 
walls  are  not  strengthened  equally  witli  other  parts  of  the  large  intestine  by  encircling 
bands. 

*  Tlie  danger  of  this  may  perhaps  be  diminished  by  tlie  use  of  a  trocar  (p.  G09). 

f  Diseases  oj  the  Rectum,  p.  228. 


606  OPERATIONS  ON  THE  ABDOMEN. 

tracted  and  very  hard  to  find ;  («5)  in  addition  to  the  irregularities  in 
the  position  of  the  colon  which  have  already  been  mentioned,  a  meso- 
colon is  frequently  present* 

Mr.  Morrant  Baker,t  as  far  as  I  know,  is  the  only  surgeon  who  has 
of  late  years  advocated  the  lumbar  operation  in  cases  of  imperforate 
rectum.  His  reasons  appear  to  be  that  he  thinks  that  Amussat's  opera- 
tion gives  these  cases  "  a  good  chance  of  an  unwounded  peritoneum," 
and  that  those  who  think  Littre's  operation  the  better  one  do  so 
on  insufficient  grounds.  It  is  noteworthy  that  Mr.  Baker's  case,  though 
most  successful  and  alive  when  last  heard  of,  nearly  three  years  after 
the  operation,  was  not  sent  to  him  till  the  nineteenth  day  after  birth, 
when  "  the  abdomen  was  enormously  distended,  and  the  vomiting  fre- 
quent, and  the  child  much  exhausted."  No  doubt  if  we  could  always 
thus  defer  operating  in  these  cases,  lumbar  colotomy  would  be  rendered 
much  safer,  but  the  peril  of  the  children  would  be  much  increased. 
But  from  my  experience  at  Guy's  and  the  Children's  Hospital  with 
which  I  am  connected,  the  surgeon  is  called  upon  to  interfere  long 
before  this.  The  question  was  raised  by  M.  Huguier  J  whether,  when 
the  inguinal  operation  was  going  to  be  performed,  the  right  loin  should 
not  be  chosen,  as  he  considered  that  on  this  side  the  surgeon  was  more 
certain  to  reach  some  part  of  the  large  intestine.  M.  Giraldes,  §  on  the 
other  hand,  has  shown  that  all  the  inquiries  undertaken  to  elucidate 
this  subject  tend  to  show  clearly  that  the  surgeon  may  rely  on  finding 
the  sigmoid  in  the  left  groin.  "  Numerous  anatomical  investigations, 
together  with  the  records  of  those  of  Curling  and  Bourcart,  have  shown 
me  that  in  the  great  majority  of  cases  in  the  foetus  and  newly  born 
child  the  sigmoid  flexure  is  placed  on  the  left  and  not  on  the  right. 
In  134  autopsies  below  the  age  of  a  fortnight  I  found  the  sigmoid 
flexure  on  the  left  side  in  114;  in  50  cases  of  Littre's  operation  which 
I  have  collected  the  operator  always  met  with  the  sigmoid  flexure  on 
the  left  side;  in  30  post-mortem  examinations  of  infants  operated  on 
for  imperforation  the  intestine  was  always  found  on  the  left;  in  100 
examinations  of  new-born  children  Curling  found  the  sigmoid  flexure 

*  Mr.  Curling  (loc.  supra  cit.)  gives  the  results  of  twenty  dissections  on  the  bodies 
of  infants,  both  operations  having  been  first  performed.  In  eighteen  out  of  the  twenty, 
Littre's  operation  was  found  easy,  whether  the  bowel  was  distended  or  no.  In  two, 
this  operation  failed,  as  the  colon  crossed  the  spine  to  run  down,  on  the  right  side,  into 
the  pelvis.  In  eight  out  of  the  twenty  subjects,  lumbar  colotomy  was  easily  performed, 
without  opening  the  peritoneum.  In  six,  the  operation  was  "  more  or  less  difficult," 
and,  as  Mr.  Curling  remarks,  the  difficulties  would  have  been  increased  in  the  living. 
In  six,  lumbar  colotomy  was  impossible  owing  to  the  distinctness  and  looseness  of  the 
meso-colon. 

t  Clin.  Soc.  Trans.,  vol.  xii.  p.  240. 

X  Bull,  de  I'Acad.  de  Med.,  torn.  xxiv.  p.  445. 

I  Leg.  Cliniq.,  p.  121.     Quoted  by  Mr.  Holmes  {Di^.  of  Children,  p.  179). 


INGUINAL    COLOTOMY.  607 

on  the  left  side  85  times ;  and  Bourcart,  who  made  prolonged  researches 
in  order  to  elucidate  this  question,  found  the  sigmoid  flexure  in  its 
*normal  position  117  times  out  of  150." 

2.  It  has  been  proposed  by  some  surgeons — e.g.,  Mr.  Reeves  and  Mr. 
H.  Allingham* — to  perform  inguinal  instead  of  lumbar  colotomy 
in  those  cases  of  malignant  ulceration  which  are  by  the  majority  of 
surgeons  considered  to  call  for  the  latter  operation.  The  following 
are  the  reasons  given  by  the  latter  surgeon :  (a)  The  position  for  the 
administration  of  anaesthetics  is  better  if  the  abdomen  be  distended. 
To  this  I  should  reply  that  the  cases  are  comparatively  few  in  which 
colotomy  is  performed  with  much  distension  present,  and  that,  with 
increasing  carefulness  in  diagnosis,  it  should  always  be  easy  in  these 
cases  of  chronic  obstruction  to  prepare  the  patient  for  submitting  to 
this  operation  before  much  distension  is  present,  and  at  a  time  when 
the  operation  by  two  stages  can  be  performed.  (/?)  The  sigmoid  does 
not  tend  to  fall  away  from  the  wound.  This  is  no  doubt  sometimes 
troublesome  in  lumbar  colotomy,  in  spite  of  an  assistant  making  firm 
pressure  on  the  abdomen,  (y)  Mr.  Allingham  thinks  that  the  diffi- 
culties of  a  lumbar  colotomy  are  so  great  as  frequently  to  end  in  the 
peritoneum  being  opened.  Having  seen  one  case  in  which  it  was 
found  needful  to  open  the  peritoneum  and  insert  the  hand  to  discover 
the  ascending  colon,  and  in  which  the  patient  did  well,  he  goes  on  to 
say,  "  Since  that  case,  when  performing  lumbar  colotomy,  after  a  fair 
trial  has  been  made  to  find  the  gut  which  fails,  I  always  purposely 
make  a  small  opening  in  the  peritoneum,  introduce  my  finger,  and 
feel  for  the  gut ;  if  this  does  not  succeed,  I  enlarge  the  opening  and 
introduce  my  hand  into  the  belly ;  by  one  of  these  means  one  cannot 
fail  to  find  the  large  intestine."  Without  disputing  the  truth  of  this 
last  remark,  it  would  be  interesting  to  know  the  results  if  it  were  need- 
ful to  perform  colotomy  in  this  way  on  a  large  scale.  {S)  Mr.  Allingham 
does  not  think  much  of  the  objection  to  inguinal  colotomy  in  these 
cases,  that  it  is  too  near  the  disease,  as  he  has  found  from  experiments 
on  the  dead  body  that,  as  a  rule,  only  4  inches  intervene  between  the 
inguinal  and  lumbar  operations,  and  as  cancer  of  the  sigmoid  flexure 
is  so  rarely  met  witli.  With  regard  to  the  first  of  these  points  I  would 
suggest  that  an  artificial  anus  placed  4  inches  away  from  the  disease 
may  be  a  very  different  thing  as  regards  the  comfort  of  the  patient  to 
one  placed  close  to  it.  As  to  the  rareness  of  disease  in  the  sigmoid 
flexure,  the  remark  of  Mr.  Arlington  does  not  coincide  with  the  expe- 
rience of  Dr.  Brunton  and  Dr.  Fagge  (p.  594). 

It  will  be  seen  that  I  do  not  agree  with  the  reasons  brought  forward 
by  Mr.  Allingham  for  preferring  the  inguinal  operation.     One  point  I 

*  Brit.  Med.  Journ.,  1887,  vol.  ii.  p.  874. 


608  OPERATIONS  ON  THE  ABDOMEN. 

think  has  not  had  sufficient  prominence  given  it,  and  will,  for  some 
time  at  least,  prevent  the  inguinal  operation  displacing  the  lumbar, 
and  that  is,  the  fact  that  the  peritoneum  must  be  opened  in  the 
former,  while  in  the  latter  it  is  only  exceptional  to  do  so.  I  cannot 
agree  with  Mr.  Allingham  in  his  words,  "  Now  that  surgery,  through 
perfect  cleanliness,  has  made  such  gigantic  strides,  and  the  peritoneum 
is  no  longer  held  in  awe  as  in  former  days,  the  opening  of  that  serous 
cavity,  if  due  care  be  taken,  does  not  to  any  great  extent  increase  the 
dangers  of  the  operation,  and  is  certainly  not  more  harmful  to  the 
patient  than  the  disturbance  of  cellular  tissue  and  parts  around,  so 
frequently  incurred  when  there  is  difficulty  in  finding  the  bowel  in 
lumbar  colotomy."  Even  if  a  larger  number  of  cases  of  inguinal 
colotomy  show  the  operation  to  be  as  safe  as  it  was  in  Mr.  Allingham 's 
hands  in  five  cases,  I  cannot  think  this  operation  so  generally  suited 
to  all  cases,  and  to  all  operators,  as  the  lumbar  one.  Difficult 
as  this  undoubtedly  is  sometimes,  and  I  have  not  made  light  of  this 
matter  (p.  601),  I  think  that  the  difficulties  are  not  likely  to  produce 
such  serious  results  as  a  general  adoption  of  inguinal  colotomy,  with 
its  needful  opening  of  the  peritoneum. 

I  have  no  space  here  to  discuss  the  question  as  to  whether  an  anus 
in  the  loin  is  superior  to  one  in  the  groin.  While  I  am  aware  that 
French  surgeons  *  have  published  several  cases  in  which  patients  with 
Littre's  operation  have  grown  up,  gone  into  society,  and  married,  I 
should  have  thought  that  one  in  the  groin  would  have  been,  for  obvi- 
ous reasons,  more  repulsive  in  the  relations  of  adult  life. 

Operation. — The  parts  being  duly  cleansed,  an  incision  li  to  3 
inches  long,  according  to  the  age  and  fatness  of  the  patient,  is  made 
parallel  with  the  outer  third  of  Poupart's  ligament  and  about  J  inch 
above  it.  The  structures  are  divided  partly  with  the  knife,  and  more 
deeply  with  the  point  of  a  steel  director,  the  muscular  branch  of  the 
circumflex  iliac  given  off  near  the  anterior  superior  spine  being  thus 
torn  through  in  a  child,  and  secured  in  an  adult.  The  transversalis 
fascia  being  reached,  it  is  slit  up,  and  all  haemorrhage  most  carefully 
arrested  before  the  peritoneum  is  opened.  This  is  then  incised  for 
about  1  inch,  and  in  an  adult  especially  should  be  united  to  the  cut 
muscle  and  skin  with  a  few  points  of  suture,  one  or  two  sponges 
attached  to  silk  being  first  inserted  to  prevent  any  blood  entering  the 
peritoneal  cavity.  The  surgeon  then  examines  the  piece  of  intestine 
which  has  first  presented  into  the  wound.  If  there  be  any  doubt  about 
this,  it  should  be  gently  pulled  upon ;  if  the  coil  comes  out  readily 

*  See  the  quotations  from  M.  Rochard's  paper  in  Mr.  Holmes'  Surg.  Dis.  of  Children, 
p.  173.  M.  Rochard  lived  in  Brest,  where  malformation  of  the  rectum  is  said  to  be 
extremelv  common. 


INGUIXAL   COLOTOMY.  609 

with  a  well-defined  mesentery,  it  is  of  course  small  intestine.  Large 
intestine,  on  the  other  hand,  is  more  fixed,  its  mesentery  is  attached 
to  the  left  side,*  while  it  shows,  in  an  adult,  longitudinal  bands  and 
appendices  epiploica?. 

The  intestine  is  now  stitched  with  fine  carbolized-silk  sutures  to  the 
surrounding  edges  of  the  wound,  the  stitches  not  taking  up  if  possible 
the  mucous  coat.  The  peritoneal  surface  of  the  intestine  is  thus 
closely  opposed  to  the  parietal  peritoneum  stitched  around  the  wound. 
During  all  these  steps  the  greatest  care  should  be  taken  to  prevent  any 
fluids  or  gas  reaching  the  peritoneal  cavity,  and  any  sponges  introduced 
are  withdrawn  one  by  one  as  the  surgeon  unites  the  circumference  of 
the  intestine  and  the  wound,  paying  particular  attention  to  the  parts 
around  the  spot  where  he  intends  to  open  the  intestine,  and  also  to 
the  angles  of  the  wound. 

If  opening  the  bowel  ma}'  be  deferred,  a  little  iodoform  being 
dusted  on,  dry  dressings  are  ajiplied  and  left  undisturbed,  if  possible, 
to  the  third  day.f 

If  it  is  needful  to  open  the  intestine  at  once,  or  soon  after  the 
operation,  this  should  be  done,  as  Mr.  Barker  X  advises,  with  a  trocar- 
puncture.  In  an  infant,  and  adults  with  distension,  there  will  be 
meconium  or  probably  sufficient  fluid  fteces  to  run  off  in  this  way 
and  give  relief,  thus  avoiding  risk  of  contamination  to  the  peritoneal 
cavity. 

Mr.  H.  Allingham,  in  order  to  secure  the  formation  of  a  good  spur, 
and  thus  to  prevent  the  passage  of  faeces  below  the  opening  and  over 
the  growth,  recommends  the  following  way  of  treating  the  bowel : 
"  When  the  gut  is  found  and  brought  to  the  surface,  I  look  for  a  piece 
with  a  sufficient  mesentery  ;  of  course  this  can  only  be  done  if  the 
disease  is  in  the  rectum  or  lower  part  of  the  sigmoid,  for  only  the  part 

of  the  sigmoid  first  picked  up  has  quite  sufficient  mesentery A 

needle  threaded  with  carbolized  silk  is  passed  through  the  mesentery 
close  to  the  intestine  on  both  sides,  then  through  the  abdominal  walls 
on  both  sides  nearer  the  lower  than  the  upper  angle  of  the  wound, 
and  these  are  tied  up  tight.  If  there  is  little  or  no  meso-colon,  I  am 
obliged  to  pass  tlie  suture  through  the  muscular  and  serous  coats  of 
the  gut  at  its  ])osterior  part.  Leaving  a  piece  of  loose  gut  outside  the 
wound,  I  next  sew  it  all  round  the  skin,  passing  the  thread  only 
through  the  muscular  and  serous  coats  of  the  gut  at  its  posterior 
part To  open  the  gut  I  use  scissors,  cutting  the  intestine  from 

*  Cripps,  Dmasefi  of  Redum  and  Anue,  p.  46. 

t  As  stated  in  the  account  of  coiotomy  and  gastrostomy  by  two  stages,  the  exposed 
surface  of  the  visciis  is  so  altered  with  lyiiipli,  etc.,  tiiat  a  guiding  stitch  should  always 
be  made  use  of  in  adults. 

X  Man.  of  Surg.  Oper.,  p.  309. 

39 


610  OPERATIONS    ON   THE    ABDOMEN". 

above  doM'^nwards  to  the  extent  of  about  H  inch  ;  through  the  incision 
can  be  seen  two  orifices  separated  by  a  well-formed  spur,  the  upper 
opening  being  the  larger,  the  lower  the  smaller."  The  lower  of  these 
is  only  required  to  clear  out  the  rectum  and  to  allow  any  retained 
fteces,  etc.,  to  come  up.  Mr.  Allingham  points  out  that  it  is  import- 
ant to  fasten  the  gut  well  outside  of  the  wound,  for  it  is  only  by  so 
doing  that  a  good  spur  and  its  results  are  obtained. 


CHAPTER  IV. 

OPERATIONS  ON  THE  KIDNEY. 

NEPHROTOMY  —  NEPHRO-LITHOTOM  Y  —  NEPHREO- 
TOMY— NEPHRORRAPHY. 

NEPHROTOMY. 

As  this  operation  is  performed  by  the  same  steps  which  form  the 
preliminaries  of  more  important  operations,*  and  as  the  conditions 
which  call  for  it  are  dealt  with  a  little  later,t  it  will  be  only  briefly 
considered  here. 

Indications.^ — Partly  as  an  exploratory  and  partly  as  a  curative 
step.  (1)  In  hydro-nephrosis  resisting  tapping.  (2)  In  pyonephrosis, 
the  pelvis  and  ureter  being  carefully  explored.  (3)- In  tul)ercular 
kidney,  and  in  suppression  of  iirine,  probably  calculous. 

Operation. — The  kidney,  l>eing  exposed  by  the  incision  given 
fully  below,  is  punctured  with  a  fine  trocar,  and  the  puncture  con- 
verted into  a  small  incision,  which  is  plugged  with  the  finger,  and 
dilated  with  this  and  dressing-forceps.  An  assistant  steadies  the 
organ  by  firm  pressure  from  the  front.  When  the  fluid  has  been 
evacuated,  very  free  drainage  must  be  provided,  by  the  largest  sized 
drainage-tube,  any  cyst  opened  being  stitched  to  the  margins  of  the 
wound,  and  the  same  precaution  being  adopted  in  the  case  of  a  sup- 
purating kidney  which  drops  down  much,  and  will  probably  allow  of 
septic  leakage  into  the  cut  planes  of  cellular  tissue. 

Haemorrhage  is  not  unfrequently  met  with  in  the  form  of  trouble- 
some oozing  from  a  suppurating  kidney.  In  a  delicate  tubercular 
patient  this  must  be  promptly  arrested  by  plugging  the  wound  in  the 
kidney  itself  by  strips  of  aseptic  gauze  carefully  packed  around  the 
drainage-tube,  and  ]>andaging  with  firm,  even  pressure. 

*  See  the  full  account  of  nephro-lithotomy,  p.  613. 

f  E.g.,  tubercular  kidney,  at  p.  623 ;  hydro-nephrosis,  at  p.  624. 


K  EPH  RO-LITHOTOM  Y.  611 

NEPHRO-LITHOTOMY. 

Indications. — Before  deciding  to  perform  the  above  operation, 
safe  as  it  usually  is,  the  surgeon  should  carefully  consider  the  follow- 
ing points : 

A.  Evidence  of  Existence  of  a  Renal  Calculus. — Some  of  the  following 
will  usually  be  present,  though  the  way  in  which  renal  calculi,  even 
of  large  size,  are  sometimes  tolerated  without  any  symptoms  what- 
ever, is  remarkable  and  well  known  (pp.  613,  620). 

i.  Pain.  This  is  usually  twofold,  (a)  Constant,  dull,  aching,  fixed 
just  below  the  last  rib  and  outside  the  quadratus  lumborum.  (6)  Ra- 
diating along  the  branches  of  the  lumbar  plexus — e.g.,  into  the  lower 
part  of  abdomen,  hip,  thigh,  and  testicle.*  These  pains  are  made 
worse  after  exercise,  any  rough  walking  or  jolting,  repeated  flexion  of 
the  thigh,t  or  lateral  twisting  of  the  body.  It  is  often  felt  severely  at 
night,  a  fact  which  may  be  explained  in  two  ways.  Thus,  Mr.  Morris 
thinks  it  is  due  to  the  passage  of  flatus  in  the  colon  over  the  kidney 
and  calculus.  It  may  also  be  explained  by  the  probable  concen- 
tration of  the  urine  at  this  time. 

The  })aiu  of  renal  calculus  has  occasional  exacerbations  of  two 
different  kinds — (1)  Those  due  to  the  passage  of  a  renal  calculus 
well  known,  and  needing  no  further  mention  here.  (2)  Others,  often 
repeated  and  periodic,  without  any  passage  of  stone;  these  are 
probal;)]y  due  to  additional  deposit  on  the  surf^ice  of  the  calculus,  or 
to  temporary  interference  with  the  exit  of  the  urine  from  the  kidney. 

ii.  Tenderness  in  the  loin,  and,  perhaps,  rigidity  of  the  muscles. 

iii.  Htematuria.  This  is  almost  always  present  at  some  time  or 
another,  at  least  to  microscopic  examination,  especially  if  the  calculus 
is  in  the  kidney  tissue,  or  a  calyx,  not  in  the  pelvis.  It  is  most  pro- 
fuse after  exercise.  This,  on  the  whole  the  most  valuable  sign  (vide 
infra),  was  entirely  absent  in  the  case  of  the  patient  from  whom  I 
removed  the  smaller  stone  figured  on  p.  622.  No  amount  of  running 
up  and  down  stairs,  practicing  twisting  movements  of  the  spine,  or 
frequent  flexing  the  thigh  on  the  abdomen  ever  produced  hsematuria. 
I  often  thought  that  if  it  had  been  justifiable  to  persuade  him  to 

*  In  a  case  of  Mr.  Biitlin's  {din.  Soc.  Trans.,  vol.  xv.  p.  113)  the  patient  sought 
relief  from  severe  neuralgia  of  the  rigiit  testis,  which  was  generally  retracted  and 
extremely  tender.  Later  on  it  was  noticed  tiiat  tliese  neuraljjjic  attacks  were  associated 
with  some  lumbar  pain  and  tenderness.  Complete  recovery  followed  after  tlie  removal 
of  a  small,  prickly,  calcium  oxalate  calculus  from  the  pelvis  of  the  right  kidney. 

t  As  in  going  upstairs,  probably  from  the  pressure  on  the  kidney  by  the  contracting 
psoas.  But  the  relation  of  the  pain  to  movement,  and  the  kind  of  movement  which 
most  induces  pain,  vary  greatly.  Thus  Mr.  Butlin's  patient  is  .said  to  have  suffered 
greatest  pain  when  driving,  least  wlien  riding.  Prolonged  walking  seems  the  most 
frequent  cause. 


612  OPERATIONS  ON  THE  ABDOMEN. 

"  stand  a  back  "  in  leap-frog  the  al)Ove  decisive  s^'mptom  might  have 
been  obtained. 

iv.  Examination  of  the  urine.  By  this  information  may  be  ob- 
tained as  to  the  presence  of  uric-acid  or  lime-oxalate  crystals,  or  blood 
discs,  the  information  being  important  according  to  their  frequency. 

V.  History  of  the  patient,  as  bearing  on  his  liability  to  oxaluria  or 
lithiasis.  Of  these,  the  former,  formed  in  the  kidney  itself,  is  brought 
about  by  imperfect  oxidation  and  metamorphosis  both  of  tissues  and 
foods — e.g.^  by  (1)  abuse  both  of  nitrogenous  and  non-nitrogenous 
foods,  viz.,  starch  and  sugar ;  (2)  insufficient  oxidation  and  deficiency 
of  red-blood  corpuscles ;  (3)  sedentary  habits ;  (4)  a  jaded  nervous 
system  going  with  over-much  head-work,  over-fatigue,  sexual  hypo- 
chondriasis. Lithiasis,  on  the  other  hand,  is  due  to  hepatic  derange- 
ment, leading  to  the  production  of  insoluble  lithic  acid  and  lithates 
instead  of  soluble  urea.  Thus  the  importance  of  a  history  of  generous 
living  and  little  exercise,  habitual  surfeiting  from  dining  out,  etc. 

B.  Failure  of  Previous  Treatment  to  give  Relief. 

C.  Inability  to  Work  from  Inevitable  Attacks  of  Pain. 

D.  Absence  of  Symptoms  referable  to  the  other  Kidney. 

E.  The  Urine. — This  should  be  as  nearly  normal  as  possible,  both 
in  amount  and  as  to  the  proportion  of  solids,  especially  urea.  The 
percentage  of  this,  with  ordinary  diet,  should  be  about  2.  The  re- 
action of  the  urine  should  be  distinctly  acid,  and  its  daily  amount 
about  2  pints.  The  temperature  of  the  patient,  the  state  of  his  skin, 
and  his  power  to  assimilate  food  should  also  be  carefully  noted. 

Preparatory  Treatment  before  Operation. — The  diet  should 
be  very  simple,  mainly  fluids — e.g.,  thin  soups,  a  little  white  fish,  game 
or  poultry,  poached  eggs,  light  puddings,  flavored,  not  sweetened, 
jellies.  Sufficient  water  to  sluice  out  the  kidneys,  and  prevent  con- 
centration and  formation  of  crystals— #.^.,  soda-water,  Apollinaris, 
Salutaris,  well-diluted  whisky,  or  Marsala.  Attention  should  also  be 
paid  to  the  bowels  and  skin.  All  chills  should  be  scrupulously 
avoided. 

Conditions  simulating  Renal  Calculus.— Some  attention  will 
here  be  given  to  this  point.  For  while  the  operative  treatment  has 
been  placed  on  a  firm  basis,  the  diagnosis  is  still,  not  unfrcquently,at 
fault. 

Putting  aside  lithiasis  as  giving  rise  to  the  passage  of  acid  urine, 
crystals,  and  thus  pain ;  movable  kidney  as,  while  painful,  causing 
very  difl"erent  pain,  not  producing  hseraaturia,and  as  being  associated 
with  certain  other  well-known  evidence,  there  remain  a  few  other  con- 
ditions which  very  closely  simulate  renal  calculus.  These  are,  first 
and  foremost,  a  tubercular  kidney,  before  it  is  advanced,  with  its  pain, 
a  certain  amount  of  hsematuria,  and  frequent  micturition.     Probably, 


NEPHRO-LITHOTOMY.  613 

however,  the  pus  being  in  excess  here  will  give  a  hint  as  to  the  nature 
of  the  disease.  Bacilli  detected  in  the  urine  will  be  decisive."^  My 
old  friend  George  Wright,t  of  Manchester,  lays  stress  upon  the  fact 
(previously  mentioned  by  Mr.  Bennet  May|)  that  in  some  cases  spinal 
caries  may  very  closely  simulate  renal  calculus.  The  following  are  his 
words :  If  "  we  remember  the  great  number  of  symptoms  which  may 
be  present  in  renal  calculus,  and,  on  the  other  hand,  bear  in  mind  that 
no  two  of  them  necessarily  co-exist  in  cases  where  a  stone  is  present, 
we  shall  see  that  there  is  occasionally  much  difficulty.  Thus,  where 
a  local  patch  of  caries  of  a  vertebral  body  exists,  and  especially  where 
deep  suppuration  occurs  and  i:>resses  upon  the  kidney,  as  in  a  case  of 
my  own  and  one  or  two  others  that  I  have  seen,  nearly  all  the  symp- 
toms of  calculus  have  been  present.  In  my  own  case,  without  any 
deformity  or  tenderness  of  the  spine,  there  was  unilateral  rigidity, 
testicular  pain,  intermissions  of  symptoms,  increased  frequency  of 
micturition,  nausea  during  attacks,  and  oxaluria,  with  local  pain  and 
tenderness ;  subsequently  an  abscess  developed,  and,  on  exploration, 
a  small  patch  of  caries  was  found,  and  the  kidney  was  felt  exposed  in 
the  anterior  wall  of  the  abscess  cavity." 

Quite  a  different  condition,  in  a  case  of  my  own,  so  closely  imitated 
renal  calculus  that  it  deserves  mention.  A  man,  born  and  having 
passed  his  early  boyhood  in  Norfolk,  Avas  in  childhood  cut  for  stone 
in  the  bladder,  by  Mr.  Birkett,  in  Guy's  Hospital.  As  he  grew  up  he 
followed  the  sedentary  occupation  of  a  tailor,  and  passed  gravel  at 
times.  He  came  under  my  care  for  pain  in  the  right  loin,  fixed  just 
below  the  last  rib  and  outside  the  quadratus  lumborum,  but  also  radi- 
ating into  the  thigh,  buttock,  and  abdomen ;  hematuria  and  frequent 
micturition  were  present  in  addition.  Careful  examination  of  the 
bladder§  giving  negative  results,  the  right  kidney  was  explored,  but 
thorough  manipulation,  aided  by  frequent  acupuncture,  revealed 
nothing.  Five  days  later  the  patient  died  very  suddenly.  A  small 
mass  of  carcinoma  involved  the  rigr^^  twelfth  dorsal  nerve  just  outside 

*  An  examination  of  the  viscera,  including  testis,  cord,  prostate,  and  vesiculse  senai- 
nales,  will,  of  couise,  help  in  doubtful  cases. 

t  Med.  Chron  ,  vol.  v.  No.  6,  p.  462.  The  following  are  the  concluding  words  of  this 
interesting  paper :  "  My  own  conclusion  is  that  renal  hsematuria  is  the  only  single 
symptom  of  anything  like  cardinal  importance,  and  that  this,  if  the  trouble  is  of  more 
than  a  year's  standing,  and  there  is  no  evidence  of  nephritis,  and  there  is  no  tumor  to 
be  felt,  makes  the  diagnosis  of  calculus  fairly  certain." 

X  Birminc/ham  Med.  Review,  January,  1887. 

§  The  haeniatnria,  frequent  micturition,  and  acid  urine  led  me  to  discuss  the  proba- 
bility of  growth  in  the  bladder.  The  urine  was  rei)eatedly  examined  for  cells,  and  tlie 
bladder  was  sounded  under  chloroform  in  the  ho])e  of  detaching  some  growth.  Tliis 
was,  however,  nullified  by  the  position  which  the  primary  gro\Mh  occupied,  and  by  its 
small  size. 


614  OPERATIONS  OX  THE  ABDOMEN. 

its  exit  from  the  spinal  column.  This  was  secondary  to  a  patch,  very 
thin  in  depth  and  slight  in  extent,  of  soft  carcinoma,  affecting  the 
mucous  membrane  of  the  bladder,  at  the  apex  only.  The  left^  kidney 
was  occupied  by  a  large  branching  calculus,  its  cortex  being  in  the  last 
stage  of  atrophy.  The  suddenness  of  the  death  seemed  due  to  embolic 
masses  of  the  secondary  growth,  where  it  involved  the  pelvic  glands, 
eroding  and  entering  the  external  iliac  vein. 

Operation. — The  patient  being  in  much  the  same  position  as  that 
for  lumbar  colotomy,  on  the  sound  side,  with  a  firm  pillow  under  the 
opposite  flank,  the  surgeon  defines,  carefully,  the  lower  border  and 
length  of  the  last  rib.  That  this  is  nf  t  an  unimportant  detail  in  renal 
operations  is  proved  by  the  fact  that  Prof.  Dumreicher,f  of  Vienna, 
•accidentally  opened  the  pleural  cavity  during  an  attempt  to  remove  a 
pyo-nephrotic,  calculous  kidney.  Post  mortem  it  was  found  that  the 
last  rib  was  rudimentary,  that  the  pleura  projected  a  good  deal  below 
the  lower  edge  of  the  eleventh  rib,  and  that  thus,  when  the  incision 
was  'Carried  upwards,  the  accident  had  become  .unavoidable.  Dr.  Lange, 
of  New  York,  has  called  attention  to  the  investigations  of  Dr.  Holl,;|: 
of  Viejina,  on  the  frequency  of  rudimentary  development  of  the  last 
rib,  and  the  importance,  therefore,  of  counting  the  ribs  before  intended 
operations  on  the  kidney.  Dr.  Lange§  himself  shows  that,  in  some 
cases,  which  are,  however,  exceptional,  even  normal  development  of 
the  twelfth  rib  may  demand  extreme  caution,  as  the  pleura  may  pro- 
ject considerably  below  it.|| 

The  surgeon,  having  defined  the  length  and  position  of  the  lowest 
rib,  makes  an  incision,^  4  inches  long,  2  inch  below  it,  and  beginning 
about  2?  inches  from  the  spine.  The  skin  and  fasciae  being  divided, 
the  muscles — viz.,  anteri(.)r  fibres  of  the  latissimus  dorsi,  the  external 
and  internal  oblique — are  cut  through,  either  on  a  director,  or  simply 
by  light  sweeps  of  the  knife.  As  soon  as  the  yellowish-white  lumbar 
fascia  is  reached,  any  bleeding  vessels  which  have  been  temj^orarily 

*  No  history  of  pain  had  been  sjiven  here,  the  patient's  attention  having  been  drawn 
to  the  right  side,  where  so  terrible  a  cause  of  siifTering  existed.  As  bearing  on  the 
latency  of  the  calculus  here,  1  would  refer  my  readers  to  p.  620. 

t  Quoted  by  Dr.  Lange,  loc.  infra  rit. 

X  Dr.  Holl  found  that  in  quite  a  considerable  percentage  the  last  rib  is  so  abnormally 
short  that  it  does  not  reach  as  far  as  the  outer  border  of  the  sacro-luiubalis,  or  so  rudi- 
mentary that  in  some  cases  it  more  resembles  a  transverse  process ;  that  in  these  cases 
the  lower  edge  of  the  pleura  passes  from  tlie  lower  boundary  of  the  last  dorsal  vertebra, 
almost  horizontally,  towards  the  lower  edge  of  tlie  eleventh  rib. 

§  Annals  of  Surgerg.  vol.  ij.  October,  1885,  p.  *28(>. 

II  In  other  cases  the  reverse  condition  may  l.e  present;  though  the  last  rib  be  rudi- 
mentary, the  pleura  may  pass  irom  the  lower  edge  of  the  eleventh  dors.il  vertebra 
horizontally  towards  the  eleventh  rib,  and  thus  be  altogether  out  of  danger. 
Tf  The  parts  beingpreviously  cleansed  with  11. ei'cury-percbloride  solution  (1  in  1000). 


NEPHRO-LITHOTOMY.  615 

secured  with  Spencer  Wells'  forceps  are  tied  or  twisted.  If  the  last 
dorsal  nerve  cross  the  incision,  it,  together  with  its  accompanying 
vessels,  should  be  drawn  aside  and  left  untouched  if  possible.  The 
lumbar  fascia  is  next  slit  up  on  a  director.  The  peri-renal  fat  which 
next  bulges  into  the  wound  is  then  torn  through  with  two  pairs  of 
dissecting-forceps.  With  two  large  retractors  opening  up  the  wound, 
the  surgeon  continues  to  tear  through  the  above  fat*  till  he  can  see  or 
easil}^  feel  the  posterior  surface  of  the  kidney.  During  this  first  stage 
of  the  operation  the  surgeon  will  find  sometimes  that  the  muscles  are 
much  thickened  by  reflex  irritation  from  the  presence  of  the  stone, 
and,  if  the  stone  has  been  combined  with  suppuration  and  peri-renal 
inflammation,  the  tissues  will  be  more  or  less  densely  blended  and 
matted  together. 

An  assistant  now  makes  powerful  pressure  on  the  opposite  side  of 
the  abdomen  so  as  to  keep  the  kidney  up  into  the  wound,  this  being 
widely  opened  by  full-sized  retractors,  a"ided,  if  needful,  by  an  assistant 
pulling  up  the  lower  ribs  with  a  hand  previously  made  aseptic.  Thus 
the  surgeon  is  enal)led  to  examine  the  organ,  wbich  is  done  systemati- 
cally; the  finger  is  first  directed  to  the  pelvis,  then  the  posterior  sur- 
face; next,  .b}'^  passing  the  finger  round  the  outer  border,  the  anterior 
surface,  which,  as  Mr.  Howse  has  pointed  out,t  can  be  done  effectually 
by  pressing  the  kidney  back  against  the  firm  unyielding  psoas.  The 
sensation  given  by  a  stone  has  been  comjDared  to  that  of  an  uncut  end 
of^a  pencil,!  or  the  last  joint  of  a  finger.§ 

If  no  stone  can  be  felt  by  the  exploring  finger,  a  needle  should  be 
thrust  into  the  different  parts  of  the  organ,  exploring  it  by  successive 
punctures  made  at  short  distances ;  tAvelve  or  more  such  punctures 
may  be  made.  Sonie  surgeons  have  advised  a  needle  mounted  in  a 
handle,  or  one  held  in  torsion  or  Spencer  Wells'  forceps ;  a  long  hare- 
lip pin  answers  all  the  purposes,  and  is  devoid  of  the  vibrations  which 
are  liable  to  accompany  a  needle  held  in  forceps.] | 

If  the  above  means,  aided  b}'  exploring  the  kidney  between  the  finger 
and  thvniib,  fail,  it  has  been  advised  to  incise  the  kidney  itself.  I  am 
strongly  of  opinion  that  this,  if  done  freely,  is  a  hazardous  step,  tliough 
not  so  much  from  the  immediate  bleeding.  The  haemorrhage  which 
may  occur  after  scraping  away  the  kidney  and  pelvic  tissue  over  a 
stone  of  long  standing  (Fig.  103),  and  over  which  the  kidney  substance 

*  If  tliis  fat  is  very  abundant,  some  of  it  should  be  ligatured  with  chromic  gut 
and  removed  ;  poorly  vitalized,  it  is  prone  to  supixirate  tediously  and  to  delay  healing. 

t  Clin.  Soc.  2Vnn.i.,  vol.  xvi.  p.  93. 

X  Morris. 

§  Howse,  lor.  supra  cit. 

II  If  the  kidney  is  at  all  enlarged,  a  fine  aspirator-needle  would  be  preferable  in 
case  any  pvo-  or  liydro-neplirosis  is  present  as  a  result  of  the  stone. 


616  OPERATIONS  OX  THE  ABDOMEN. 

is  atrophied,  may  be  very  free.  Such  ha3morr]iage  is  very  likely  to 
need  plugging.  If  a  free  incision  be  made  into  a  kidney  healthy  in 
size  and  structure  in  search  of  a  small  stone,  it  is  almost  certain  to  be 
followed  by  profuse  haemorrhage.  Plugging  may  arrest  this,  but  the 
haemorrhage  may  recur,  and  repeated  plugging  is  very  likely  to  lead 
to  fatal  cellulitis  and  retro-peritoneal  suppuration.'J^  Another,  and  I 
think  a  preferable,  method  of  exploring  in  doubtful  cases,  is  to  open 
the  pelvis,  or  the  thinner  kidney  tissue  close  by,  and  to  pass  a  finger 
up  into  the  organ,  so  as  to  explore  the  calyces,  and  then  down  into  the 
ureter,  in  the  hope  of  tracing  a  stone. f  If  additional  room  is  required, 
the  outer  edge  of  the  quadratus  lum);iorum  may  be  divided;  if  there 
is  still  too  little  space  for  exploring,  the  incision  should  be  converted 
into  a  T-shaped  one,  by  cutting  downwards  towards  the  crest  of  the 
ilium  with  a  probe-pointed  bistoury  from  within  outwards,  and  at  once 
securing  any  cut  vessels.  When  the  stone  is  easily  detected,  the  pelvis 
or  the  kidney  tissue  is  lacerated  by  the  finger-nail,;{:  a  curette,  or  sharp 
spoon,  and  the  stone  turned  out  or  removed  with  dressing  or  small 
lithotomy  forceps. 

If  the  stone  is  irregularly  branched§  it  may  avoid  some  laceration 
of  the  kidney  tissue  if  it  is  broken  up  and  removed  in  two  or  more 
fragments.il     In  this  case  the  bed  in  which  the  stone  has  been  lying 

*  Such  a  case  occurred  at  Birminghatn,  and  ended  fatally.  It  is  possible  that 
other  operators  may  not  have  been  so  candid. 

f  In  the  following  case  under  tlie  care  of  Mr.  T.  Jones,  of  Manchester  {Med.  Chron., 
June,  1887,  p.  212),  tills  step  of  opening  the  pelvis  alone  sufficed  to  find  the  stone,  after 
systematic  exploration  of  the  kidney  had  failed:  "The  forefinger  was  passed  to  the 
anterior  surface,  and  the  organ  grasped  between  the  finger  and  the  thumb;  nothing 
however,  could  be  felt.  The  kidney  was  then  carefully  explored  by  systematic  punc- 
ture with  a  long  needle,  also  passed  towards  the  pelvis,  but  no  calculus  could  be  found. 
An  incision,  sufiaciently  large  to  admit  tiie  tip  of  the  index-finger,  was  then  mnde 
through  the  kidney  substance  into  the  pelvis  by  means  of  a  fine  bistoury.  On  intro- 
ducing the  forefinger,  a  small  stone  was  discovered  firmly  lodged  in  (me  of  the  superior 
calyces.  Small,  straight  lithotomy  forceps  were  introduced,  and  the  stone  thus  re- 
moved." Verv  free  htenjorrhage  attended  the  above  incision,  but  it  yielded  to  pressure 
made  with  carbolized  sponges  and  kept  up  for  five  minutes.  The  patient  made  a  good 
recovery.  The  calculus,  consisting  of  lime  oxalate,  weighed  twenty  grains.  This  plan 
of  opening  the  pelvis  might  be  thought  to  cause  a  risk  of  leaving  a  urinary  fistula,  but 
the  numerous  cases  in  which  calculi  have  been  removed  from  the  renal  pelvis  with 
entire  success  do  not  support  this  view. 

X  Mr.  Morris  {Dis.  of  the  Kidney,  p.  528)  advises  the  use  of  the  finger,  as  it  will 
sufficiently  lacerate  the  kidney-tissue,  while,  at  the  same  time,  it  plugs  the  wound. 

§  The  question  of  nephrectomy,  which  may  arise  here,  is  considered  below,  p.  620. 

II  Mr.  Kendall  Franks  {Lancet,  1880,  vol.  ii.  p,  1223)  thus  removed,  piecemeal,  a 
friable  stone  weighing  171  grains,  and  composed  of  lime  carbonate  and  phosphates. 
In  this  case  the  urine  had  been  fetid,  though  acid.  The  wound  healed  by  first  inten- 
tion. In  cases  of  piecemeal-removal  of  calculi,  especially  when  friable,  a  certain 
amount  of  doubt  will  often  remain  as  to  the  entire  removal. 


KEPHRO-LITHOTOMY.  617 

should  be  freely  washed  out  with  very  dilute  carbolic  acid  or  satu- 
rated boracic-acid  lotion. 

If  the  stone  is  situated  on  the  anterior  aspect  near  the  centre  of  the 
kidney  where  the  large  vessels  lie,  the  posterior  aspect  of  the  kidney 
or  its  pelvis  had  better  be  incised  and  the  stone  pushed  through,  by 
making  pressure  on  the  front,  the  vessels  here  thus  running  no  risk 
of  damage. 

If  the  kidney  be  enlarged,  with  its  calyces  expanded  into  cysts,  on 
scratching  through  the  pelvis  over  a  stone,  the  gush  of  fluid  and  col- 
lapse of  the  expanded  kidney  may  cause  the  stone  to  disappear,  and 
thus  lead  to  much  trouble  in  its  removal  (Symonds,  Clin.  <S'oc.  Trans., 
vol.  xviii.  p.  181). 

When  the  stone  has  been  all  removed,  if  blood  continues  to  ooze 
freely,  and  there  is  nothing  to  tie,  it  must  be  stopped  by  sponge 
pressure,  either  by  pressing  sponges  on  sponge-holders  for  a  few 
minutes,  or  by  packing  the  wound  with  sponges  thoroughly  car- 
bolized  and  dusted  slightly  with  iodoform,  these  sponges  having  silk 
attached  to  admit  of  their  ready  withdrawal.  If  the  oozing  cannot 
be  arrested  by  such  pressure,  any  wound  in  the  kidney  must  be 
plugged  with  strips  of  iodoform  gauze,  which  can  probu1)ly  be  re- 
moved in  twenty-four  hours.* 

A  full-sized  drainage-tube  sliould  be  introduced  to  tlie  very  bottom 
of  the  wound,  lying  in  close  apposition  to  the  wound  in  the  kidne}' 
or  pelvis  (or  actually  in  it  if  this  wound  is  large)t  the  rest  of  the 
wound  closed,  and  aseptic  dressings  applied.  I  have  generally  used 
dry  iodoform  or  sal  alembroth  gauze  with  boracic  lint  outside,  kept 
in  situ  with  a  many-tailed  bandage.  Salicylic  wool  or  wood  wool  are 
efficient  substitutes.  Whatever  dressing  is  used  will  have  to  be 
changed  twice  dail}^  for,  in  all  probability,  three  or  four  days,  owing 
to  the  soakage  of  urine.  To  reduce  the  irritation  of  this  to  a  mini- 
mum, the  parts  around  the  wound  should  be  well  smeared  with 
eucalyptus  and  vaseline.  By  means  of  pillows  against  the  shoulders 
and  pelvis,  the  patient  should  be  kept  off  the  wound,  otlierwise  dis- 
charges will  quickly  soak  out  of  the  dressings,  and  the  drainage-tube 
will  irritate  the  wound. 

After-treatment. 

The  chief  points  here  are  : 

1.  The  meeting  of  shock  after  a  prolonged  operation. 

*  If  such  plugging  has  to  be  made  use  of,  it  should  be  carried  out  eflectively  and 
once  for  all,  olherwis-e  recurrent  bleeding  and  repeated  plugging  is  very  likely  to 
lead  to  cellulitis,  which  may  end  fatally,  to  say  nothing  of  the  painfulness  and  .shock 
caused  by  the  repetition  of  the  plugging,  unless  an  anfpstiietic  is  given. 

f  If  the  kidney  has  contained  pus  or  other  fluid  the  tube  must  be  carried  well  into 
the  cavity  of  the  organ. 


618  OPERATIONS  ON  THE  ABDOMEN. 

2.  Changing  of  the  dressing  at  sufficiently  frequent  intervals  at  first, 
according  to  the  amount  of  urine  and  hlood  which  soak  through. 

3.  Gradual  shortening  of  the  drainage-tube  instead  of  entire  re- 
moval, especiall,y  where  there  has  been  much  interference  with  the 
surrounding  parts,  or  where  pus,  etc.,  have  been  present  in  the 
kidney. 

4.  Avoidance  of  all  chills. 

5.  Appropriate  food,  mainly  the  blandest  fluids  in  regulated 
amounts,  especially  where  the  condition  of  the  other  kidney  is 
doubtful. 

Lastly,  it  may  be  pointed  out  that  the  after-histories  of  these  cases 
should  be  followed  up  most  carefully,  to  see  hoAv  far  the  cure  remains 
a  complete  one ;  to  aid  this,  the  patient  should  pay  life-long  attention 
to  his  diet,  habits,  exercise,  etc. 

DifQculties  in  Nephro-Lithotomy. 

1.  An  insufficient  incision. 

2.  Abundant  fat — e.g.,  in  the  subcutaneous  tissues,  around  the 
kidnev,  and  extra-peritoneal,  rendering  the  wound  very  deep. 

3.  Rigidity,  and  perhaps  thickening  of  the  muscles,  due  to  the 
irritation  of  the  stone.  This  condition  was  present  in  a  very  marked 
degree  in  a  patient  from  whom  I  removed  the  smaller  calcium- oxalate 
calculus  (Fig.  103).  No  amount  of  anaesthetic  seemed  to  have  any 
effect  on  this  condition.  Fortunately  the  loin  was  a  thin  one,  and 
the  stone  very  obvious  on  reaching  the  pelvis. 

3.  Matting  of  the  parts  around  the  kidney,  rendering  it  difficult  to 
explore  this  organ,  its  different  parts  and  relations  exactly. 

4.  An  indurated  condition  of  the  kidney  itself  from  the  irritation 
of  a  stone. 

5.  A  stone  present  but  very  difficult  to  detect.  This  may  be  due  to 
(a)  The  small  size  of  the  stone,*  especially  if  it  is  in  a  calyx  or  com- 
bined with  a  very  indurated  kidney.  How  exceedingly  difficult,  in 
fact,  at  times,  impossible,  it  is  to  detect  a  stone,  even  of  fair  size,  is 
shown  by  a  case  published  by  Mr.  Morris,t  in  which  this  authority, 
with  all  his  experience,  after  thoroughly  exploring  the  kidney, 
compressing  it  all  over  with  the  finger  and  thumb,  and  also  after 
puncturing  it,  failed  to  detect,  a  stone  which  lay  in  a  hollowed-out 
calyx.     Though  the  calculus  was  the  size  of  a  small  marble,  it  was  so 

*  Mr.  Havvard  {Lancet,  1886,  vol.  i.  p.  1112)  briefly  records  a  case  in  wliich  he  ex- 
plored the  kidney  in  a  patient  with  "  well-marked  symptoms  of  renal  calcniiis  wanting, 
however,  in  the  presence  of  hfematnria."  Nothing  was  fonnd,  but  the  patient  was 
believed  to  have  passed  a  stone  abont  three  months  later,  after  one  of  the  old  attacks 
of  pain.     Since  this  he  had  remained  well  up  to  the  time  of  the  re])ort. 

t  Med.-Chir.  Trans.,  vol.  xlviii.  p.  69.  The  woodcut  (p.  73)  shows  well  tiie  relation 
of  tiie  stone  to  tlie  surrounding  kidnev. 


KEPHRO-LITHOTOMY.  619 

thickly  surrounded  by  kidnej'-tissue,  that,  even  after  the  removal  of 
the  kidney,  the  position  of  the  stone  could  not  be  detected  by  press- 
ing on  the  kidney  with  the  fingers  as  it  lay  on  a  table.  The  patient 
made  a  good  recover3\ 

(6)  A  sacculated  kidney,  into  one  of  which  sacculi  a  small  stone, 
may  fall  and  be  hard  to  find  (p.  617). 

6.  A  stone  on  the  anterior  surface  of  the  kidney,  especially  if  near 
the  entrance  of  the  vessels  (p.  617). 

7.  A  ver}^  large  or  a  branching  stone.  Mere  size  does  not  neces- 
sarily create  difficulties  in  extraction,  though,  owing  to  the  changes 
entailed  in  the  kidneys,  the  general  health,  etc.,  by  the  long  duration 
of  a  calculus,  the  prognosis  is  rendered  very  much  less  favorable.  Thus, 
in  the  calculus  (Fig.  103)  weighing  473  grains,  or  very  nearly  an  ounce, 
the  very  bulk  of  the  stone  rendered  its  detection  easy  ;  it  was  readily 
loosened  from  the  much-dilated  pelvis  with  lithotomy-forceps.  A 
branched  calculus  presents,  of  course,  much  greater  difficulties.  iNIr. 
Bennet  May  *  has  published  an  excellent  instance  of  this  kind  in 
which  he  successfully  removed  a  very  large  somewhat  S-shaped 
caculus  from  a  man  aged  thirty-four,  with  symptoms  of  sixteen  years' 
duration.  Though  the  stone  weighed  473  grains,  and  was  three 
inches  long,  manipulation  failed  to  make  it  out  distinctly,  but  acu- 
puncture detected  it  at  once.  In  such  a  case  the  kidney  tissue  must 
be  incised  over  the  stone  and  the  wound  plugged  and  then  enlarged 
with  the  finger-nail.  If  the  surgeon  finds  that  he  cannot  dislodge  the 
first  end  of  the  stone  which  he  exposes,  he  should  either  divide  the 
stone  with  a  small  pair  of  cutting-bone  forceps,  or  expose  the  other 
end,  which  may  be  smaller. 

8.  A  stone  which  breaks  up  readily.  Another  condition  allied  in 
difficulty  is  where  a  calculous  deposit  rather  than  a  distinct  calculus 
is  present.  This  is  especially  grave,  as  the  deposit  here  will  usually 
be  phosphatic,  and  point  to  co-existing  pyo-nephrosis.  These  two 
conditions  are  best  met  by  a  sufficient  opening  into  the  kidney,  re- 
moving Avith  fine  forceps,  or  scoops,  every  particle  of  stone,  and  then 
thoroughly  washing  out  the  cavity  with  boracic  acid  solution  or 
Thompson's  fluid.f 

9.  Multiple  calculi,  as  in  the  case  at  p.  620. 

10.  A  very  mobile  kidney.  The  importance  of  having  an  assistant 
to  push  the  kidney  well  up  into  the  wound  has  already  l)een  insisted 
on.     It  is  essential  to  have  this  well  done  both  for  detection  of  the 

*  Clin.  Soc.  Trans.,  %()1.  xvi.  p.  90.     The  calculus  is  well  figured  on  pi.  iv. 

f  Water,  4  oz. ;  glycerine,  4  oz. ;  Iwrax,  2  oz.  To  be  diluted  witli  water  to  1  in  10, 
or  1  in  4,  according  to  the  condition  of  the  part  syringed.  Soliiiions  of  carbolic  acid 
or  mercurv  perchloride  should  be  avoided  in  such  cases,  for  fear  of  irritation  or 
absorption. 


620  OPERATIONS  ON  THE  ABDOMEN. 

stone  and  for  its  removal,  in  order  to  avoid  needless  disturbance  of 
the  surroundinfj;  parts. 

Mr.  May  Hoc.  supra  cit.)  explains  the  remarkable  fact  that  his  large 
stone  was  not  felt  when  the  kidney  was  thoroughly  exposed  by  the 
tendency  of  this  organ  to  fall  forwards,  and  thus  embarrassingly 
increase  the  depth  of  tlie  wound. 

Question  of  Nephrectomy  during  a  Nephro-lithotomy. — 
In  several  of  the  above  conditions  the  question  of  the  advisability  of 
removal  of  the  kidney  will  arise,  e.g.,  where  the  kidney  has  been  much 
handled  and  repeatedly  incised,  where  the  stone  is  large  and  branched 
and  difficult  of  removal,  where  many  stones  are  present,  or  where  one 
is  present  and  very  friable,  where  the  kidney  is  much  altered  by  pyo- 
or  hydro-nephrosis,  and  finally  where  the  surgeon  is  certain  a  stone 
exists  but  cannot  find  it,  as  in  Mr.  Morris's  case  already  alluded  to  at 
p.  618. 

In  such  cases  the  surgeon  will  be  guided  by  tlie  age  of  the  patient; 
the  knowledge  he  possesses  as  to  the  condition  of  the  other  kidney 
(the  amount  of  urine,  the  percentage  of  urea,  etc.);  the  degree  to 
which  the  kidney  he  is  operating  on  has  been  disturbed  from  its  rela- 
tions, and  its  structure  interfered  with  ;  the  amount  of  disease,  e.g., 
number  of  sacculi,  condition  of  pus  contained  in  them,  the  thinning 
of  the  cortex,  etc.  When  the  surgeon  is  certain  from  the  history  and 
failure  of  j^revious  treatment  that  a  stone  exists  which  cannot  be 
found,  he  must  be  chiefly  guided  by  the  degree  to  which  life  has  been 
made  miserable.  Finally,  the  length  of  time  that  the  operation  of 
nephro-lithotomy  has  already  lasted,  and  the  condition  of  the  patient 
must  be  taken  into  account.  Where  the  patient  is  young,  where  the 
other  kidney  is  healthy,  where  the  kidney  operated  on  is  much  dam- 
aged either  by  previous  disease  or  by  manipulation  added  to  disease, 
where  several  stones  are  present,  nephrectomy  either  now,  or  a  little 
later,  is  indicated  ;  of  these  immediate  removal  of  the  kidney  is  pref- 
erable if  the  patient's  condition  admits  of  it.* 

*  A  case  wliicli  has  recently  been  under  my  care  illustrates  well  many  of  the  above 
difficulties — viz.,  multiple  and  large  calculi,  a  mobile  kidney,  the  question  of  nephrec- 
tomy arising  during  nephro-lithotomy,  and  the  formation  of  multiple  calculi  in  one 
kidney  without  symptoms.  In  February,  1888,  I  was  asked  by  Dr.  Goodhart  to  see  a 
case  of  probable  renal  calculus.  The  boy,  aged  fifteen,  had  been  admitted  with  ab- 
dominal pain  and  grating  of  an  indistinct  and  delicate  nature  in  the  left  renal  region. 
This  kidney  was  slightly  enlarged.  When  asked  to  localize  his  pain,  the  patient 
pointed  to  the  region  of  the  left  kidney  and  the  left  loin.  This  kidney  being  explored 
was  ibund  to  be  occupied  by  irreguhir  nodulated  masses.  A  hare-lip  pin  at  once  came 
on  and  between  calculi.  The  kidney  being  incised,  host  of  calculi,  comparable  only 
to  a  gravel-pit,  were  found  in  the  calyces  and  pelvis,  the  chief  nests  being  at  the  upper 
and  lower  extremities.  The  former  of  these,  lying  as  they  did  high  up  imder  the  ribs, 
gave  much  trouble.     To  get  at  them  the  kidney-tissue  was  again   scraped   through 


NEPHRO-LITHUTOMY.  621 

Causes  of  Death  after  Nephro-lithotomy.— Very  few  unsuc- 
cessful cases  have  been  published ;  tlie  followino-  appear  to  be  most 
probable  causes  of  after-trouble  : 

1.  Haemorrhage.  If  it  has  been  thought  needful  to  incise  the  kid- 
neys freely,  and  the  bleeding  has  been  arrested  with  difficulty  after 
imperfect  and  repeated  plugging,  it  may  readily  bring  on 

2.  Cellulitis.  Other  causes  of  this  will  be  found  in  much  disturb- 
ance of  the  wound  or  fingering  by  many  hands.     Sepsis. 

3.  Urannia,  if  the  other  kidney  is  the  site  of  calculous  disease  or 
disorganized.  This  was  chiefly  the  cause  of  death  in  the  case  in  which 
I  removed  the  large  stone  (Fig.  103).  The  patient  was  a  solicitor,  aged 
fifty-eight,  of  sedentary  life,  and  gouty  history,  wlio  liad  suffered  from 
attacks  of  right  renal  colic  off  and  on  for  upwards  of  thirty  years,  these 
attacks  becoming  increasingly  fierce  for  the  previous  six  months. 
Occasionally  he  had  had  slight  pain  on  the  left  side,  and  on  the 
morning  fixed  for  the  operation  he  passed  two  small  fawn-colored 
calculi  of  lithic  acid  and  lithates.  These  were  quite  insufficient  to 
account  for  all  his  suffering,  and  as  prolonged  and  careful  treatment 
had  entirely  failed,  and  as  his  "  life  was  not  Avorth  having  at  the  price," 
the  operation  was  proceeded  with,  and  the  huge  renal  calculus  figured 
below  removed.  This  was  affected  with  the  utmost  ease,  as  the  stone, 
from  its  size  and  hardness,  was  readily  detected  occupying  the  dis- 
tended pelvis  of  the  kidney.  A  profuse  jet  of  venous  blood  followed 
its  removal  with  lithotomy  forceps,  after  it  had  been  loosened  by  a 
scooping  movement  of  the  finger.  The  haemorrhage  was  at  once 
arrested  by  sponge-pressure  kept  up  for  a  few  minutes.    All  went  well 


directly  over  them,  and  many  of  tliem  thns  readied.  The  chief  difBculty  of  the  opera- 
tion, in  addition  to  the  number  of  stones,  was  the  great  mobility  of  the  kidney,  though 
this  organ  was  well  pushed  up  from  the  front.  The  condition  was  perhaps  due  to  the 
almost  entire  absence  of  surrounding  fat.  When  I  realized  the  condition  of  the  kidney, 
I  expressed  myself  in  favor  of  nephrectomy,  as  the  organ  was  almost  useless,  as  the 
stones  were  so  numerous,  and  as  a  prolonged  attempt  at  removal  would  produce  more 
shock  in  so  weakly  a  subject.  One  or  two  less  important  points  in  favor  of  nephrectomy 
were  the  mobility  of  the  kidney  and  entire  absence  of  adhesions.  Dr.  Goodh;irt's 
counsel  was,  however,  against  this  step,  owing  to  the  small  percentage  of  urea — this 
had  never  been  above  1.2  per  cent.,  and  often  less.  I  accordingly  continued;  when 
forty-six  calculi  had  been  removed,  and  the  operation  had  lasted  three-quarters  of  an 
hour,  the  pulse  failed  so  ominously  that  I  was  obliged  to  desist.  Very  little  blood 
escaped  as  long  as  the  opening  was  plugged  with  the  finger,  but  considerable  oozing 
followed  as  the  finger  brought  out  the  stones.  The  i>atieut  never  rallied  well,  and  died 
three  hours  and  a  half  after  the  operation.  Post-mortem  :  There  was  a  little  ecchymosis 
around  the  left  kidney;  it  still  contained  calculi  at  its  upper  and  lower  parts.  The 
rightkidney,  of  which  the  boy  had  never  complained,  also  contained  a  large  number  of 
stones.  Its  substance,  though  much  wasted,  still  contained  a  fair  amount  of  secreting 
substance.  The  condition  of  the  opposite  kidney  thus  abimdantly  justified  my  old 
friend's  opinion. 


622 


orERATIOXS  ON  THE  ABDOMEN, 


for  the  first  week,  save  for  persistent  oxaluria,  which  no  treatment 
could  remove.  The  patient  was  able  to  sit  up  and  read  ;  appetite  re- 
turned, and  the  Avound  was  healing  well.  On  the  sixth  day  a  change 
for  the  worse  set  in,  first  much  flatulence  and  nausea,  then  constant 
restlessness,  followed  by  coma,  ending  in  death  on  the  morning  of  the 
eighth  day.  I  cannot  doubt  that  the  opposite  kidney  was  here  also 
the  seat  of  stone,  and  its  tissue  too  much  impaired  to  admit  of  recov- 

FiG. 103. 


aip 


The  larger  calculus  is  the  one  mentioned  here  in  the  text.  It  weighed  473  grs.,  and  consisted 
of  lithic  acid  and  lithates.  The  main  mass  lay  in  the  dilated  pelvis,  the  processes  fitted  into  the 
calyces.  The  smaller  calculus,  composed  chiefly  of  oxalates,  was  successfully  removed  from  a 
patient  aged  twenty-four.  It  weighed  42  grs.  The  two  are  good  instances  of  what  nephro-lithot- 
omy  can,  and  what  it  cannot,  do  without  grave  risks. 

ery,  though  I  was  unable  to  obtain  a  post-mortem  examination  to 
verif}^  this.  I  should  add  that  the  urine  in  this  i:)atient  before  the 
operation  was  acid,  of  sp.  gr.  1018,  and  without  sugar  or  all)umen. 
The  quantity  passed  was  natural,  and  the  urea  sometimes  normal, 
sometimes  slightly  deficient. 

Dr.  Whipham  and  Mr.  Haward  *  have  recorded  a  case  in  a  patient 
about  the  same  age  as  my  own — viz.,  fifty-six — who  had  for  "several 
years  "  been  troubled  with  "  gravel."  The  symptoms  here  were  chiefly 
indicative  of  calculous  mischief  in  the  left  kidney,  but  there  was  some 
tenderness  on  the  right  side  as  well.  The  urine  here  was  1006  sp.  gr., 
alkaline,  and  containing  pus.  The  left  kidney  was  explored,  and 
found  in  a  state  of  pyo-nephrosis,  no  calculus  was  found,  but  a  copi- 
ous discharge  of  pus  took  place  soon  afterwards,  giving  great  relief. 
The  patient  a  little  later  again  lost  ground,  and  the  wound  was  thor- 
oughly explored  a  second  time,  but  the  patient  sank  a  few  hours  after 
this,  a  month  after  the  first  operation.  The  left  kidney  pelvis  was 
much  dilated  in  its  uj^per  part,  and  communicated  with  a  large  peri- 


Clin.  Soc.  Trans.,  vol.  xv.,  p.  123. 


NEPHRECTOMY.  623 

nephritic  abscess.  The  right  kidney  contained  a  large  branching 
calculus. 

Both  this  case  and  my  second  one  point  urgently  to  the  importance 
of  surgeons  being  permitted  to  explore  earlier  in  such  cases. 

4.  Septicaemia.  This  condition  may  be  induced  by  the  wound 
becoming  foul,  a  complication  Avhich  can  always  be  prevented  after 
removal  of  small  stones  from  healthy  kidneys.  But  where  pyo- 
nephrosis exists,  it  may  be  impossible  to  keep  the  wound  sweet  from 
the  first.  And  it  is  to  be  noted  that  septicaemia  may  occur  after  a 
nephro-lithotomy,  successful  as  far  as  the  removal  of  the  stone  goes, 
after  a  considerable  interval,  where  pyo-nephrosis  coexists.  This  is 
an  additional  reason  for  carefully  considering  tlie  advisability  of  per- 
forming nephrectomy  in  such  cases. 

Dr.  Shepherd,  of  Montreal,  has  published*  a  very  interesting 
instance  of  this  kind.  Nephro-lithotomy  was  performed  in  a  patient 
aged  twenty-six,  who  had  suffered  from  symptoms  of  stone  for  seven 
3^ears,  with  no  tumor,  and  pus  in  the  urine  varying  from  a  small  trace 
to  25  per  cent.  An  enormous,  unbreakable  stone  of  triple  phosphate 
was  removed  w'ith  much  difficulty  from  the  left  kidney.  It  weighed 
4  ozs.  and  7  drs.,  and  measured  3J  inches  in  length  and  9  inches  in 
circumference.  The  tissue  of  the  lower  part  of  the  kidney  exposed 
seemed  healthy,  and  no  pus  being  evacuated  it  Avas  thought  best  not 
to  remove  the  organ.  The  wound  continued  to  discharge  pus,  and 
the  temperature  varied  correspondingly  for  three  months  and  a  half 
after  the  operation,  when  septicaemia  set  in  and  proved  fatal.  The 
autopsy  showed  that  the  upper  part  of  the  kidney,  which  was  not  ex- 
posed, consisted  of  large  communicating  sacs,  containing  over  10  ozs. 
of  foetid  pus,  and  a  number  of  irregular  branched  calculi.  Dr.  Shep- 
herd points  out  that  the  fatal  septicaemia  was  undoubtedly  due  to 
these  abscesses,  showing  the  need  of  thorough  exploration  in  all  cases 
where  a  large  stone  has  set  up  grave  changes,  and  of  extirpation  in 
most  of  them. 

NEPHRECTOMY. 
Indications. 

i.  Cases  of  strumous  ])yelitis  or  pyo-nephrosis  explored  previously 
and  drained  b}"  nephrotomy,  but  in  wliich  a  sinus  and  discharge  per- 
sists. Here  the  kidney  should  be  removed  wdien  the  following  con- 
ditions are  favorable — viz.,  the  age  and  strength  of  the  patient,  the 
absence  of  visceral  infection,  tubercular  or  lardaceous,  and,  if  possible, 
a  date  not  too  long  deferred,  for  the  additional  reason  that  the  kidney 
will  be  increasingly  matted  down  and  difficult  of  removal,  while  its 
fellow  may  have  become  involved  in  the  disease. 

*  New  York  Med.  News,  April  23, 1887  ;  Annals  of  Surgery,  vol  vi.,  August,  1887,  p. 
185.     The  condition  of  the  opposite  kidney  is  not  mentioned. 


624  OPERATIONS  ON  THE  ABDOMEN. 

ii.  Calculous  pyelitis  or  pyo-nephrosis,  where  the  kidney  is  destroyed 
by  long  formation  of  calculi  and  consequent  suppuration,  where  the 
numerous  calculi  exist  with  sacculation  of  the  kidney,  or  where  a  large 
and  branching  calculus  is  so  imbedded  as  to  resist  removal.  These 
indications  for  nephrectomy  have  been  already  considered  under  the 
heading  Nephro-lithotomy  (p,  620),  as  it  is  during  the  performance  of 
this  operation  that  the  question  of  removing  the  kidney  for  the  above 
conditions  will  arise.* 

iii.  A  kidney  the  site  of  hydro-nephrosis,  and  resisting  repeated 
lumbar  aspirations,  and  later  on  nephrotomy  and  suture  of  the  cyst- 
margins  to  the  edges  of  the  wound,  and  aseptic  drainage.  Occasion- 
ally repeated  aspirations  are  sufficient,  as  in  Mr.  Croft'sf  case,  in  which 
eight  aspirations  (through  the  lumbar  region)  within  four  months,  be- 
tween three  and  four  pints  being  withdrawn  each  time,  sufficed  to 
cure  a  hydro-nephrosis  in  a  boy  aged  twelve.  It  is  noteworthy  that 
the  case  was  distinctly  traumatic  in  origin  and  that  the  last  fluid  with- 
drawn contained  a  very  large  amount  of  albumen. 

In  deciding  here  between  nephrotomy  followed  by  drainage,  after 
suturing  the  sac  to  the  wound-edges,  and  nephrectomy,  the  surgeon 
will  be  guided  mainly  by  the  time  that  the  case  has  lasted,  the  age  and 
health  of  the  patient,  and  the  condition  of  the  other  kidney.  On  the 
one  hand,  Mr.  Morris'];  writes  thus  of  drainage:  "This  practice  has 
been  very  successful,  and  ought  certainly  to  be  adopted  when  aspira- 
tion fails  and  before  nephrectomy  is  dreamt  of.  Of  seventeen  cases 
collected  by  Staples, §  all  recovered,  though,  in  more  than  half  of  them, 
it  is  stated  that  a  fistula  in  the  loin  was  formed.  In  a  few  cases  a  com- 
plete cure  will  be  effected,  and  the  wound  will  quite  close.  In  most 
cases,  however,  a  fistula  must  be  expected ;  but  the  fistula  gives  little 
inconvenience  to  a  person  of  ordinary  intelligence  and  patience."  Mr. 
Morris  gives  three  cases  in  support  of  this  opinion,  two  of  whom  were 
certainly  leading  very  active  and  useful  lives. 

On  the  other  hand,  some  authorities — e.g.,  Mr.  Barker|| — thinks 
much  less  highly  of  drainage.     "  Free  drainage  of  hydro-nephrosis  is 

*  The  above  conditions  are  put  first,  as  it  is  tlieir  frequency  and  the  slow,  but  in- 
evitable destruction  of  the  kidneys  which  they  bring  about  that  make  them  the  most 
frequent  indications  for  nephrectomy.  In  fact,  it  is  probable  that  further  experience 
will  show  that  extirpation  of  the  kidney  is  chiefly  called  for  in  such  inflammatory  or 
suppurating  conditions  and  for  new  growths  in  tlieir  early  stage. 

t  Clin.  Soc.  Trans.,  vol.  xiv.  p.  107. 

X  Surg.  Dis.  of  the  Kidney,  p.  323.  Dr.  Weir,  of  New  York  (Annals  of  Surgery, 
April,  1885),  implies  that  Billroth  ("Ueber  Nierenexstirpation,"  Wien.  Med.  Woeh., 
Nos.  24,  25,  26,  1884)  is  in  favor  of  drainage  in  these  cases  in  preference  to  nephrec- 
tomy. 

§  Journ.  Arner,  Med.  Assoc,  April,  1884. 

II   Diet,  of  Surg.,  vol.  i.  p.  761. 


NEPHRECTOMY.  625 

not  much  more  successful  than  aspiration,  and  is  not  devoid  of  risks. 
Of  course  a  large  sac  will  be  in  a  better  position  to  contract  if  freeh' 
and  continuously  drained  than  if  only  occasionally  emptied.  But  the 
time  consumed  in  the  process  is  usually  very  great,  and  the  patient 
often  suffers  great  distress  from  the  process  of  drainage,  and  the 
necessity,  lasting  for  months,  for  constantl)'^  changing  the  wet  dress- 
ings. Again,  there  is  always  the  risk  of  suppuration  in  the  sac,  with 
consequent  septic  infection."  Mr.  Barker  is,  therefore,  inclined  towards 
nephrectomy  at  once,  or,  at  all  events,  after  a  sufhciently  free  l)ut  short 
drainage. 

From  observation  of  two  cases  in  which  incision  and  drainage  had 
been  made  use  of,  I  should  quite  agree  with  Mr.  B  irkt^r,  especially 
when  the  patient  is  young  and  the  case  is  at  a  standstill  after  about 
two  months  of  drainage.  Mr.  Morris  evidently  considers  that  the 
troubles  of  a  renal  fistula  can  be  met  by  the  permanent  wearing  of  a 
lumbar  urinal.^  I  would  submit  that  in  hospital  patients,  certainly, 
this  will  meet  the  case  very  imperfectly.  It  will  too  often  be  neglected 
and  laid  aside,  especially  by  young  patients,  leading  to  an  eczematous 
raw  area  round  the  sinus,  which  itself,  in  one  case  I  saw,  contained 
foul  phosphatic  material.  Where,  therefore,  the  patients  are  young, 
with  every  prospect  of  a  long  and  active  life  before  them,  where  about 
two  months'  drainage  have  failed  to  bring  about  any  considerable 
alteration  in  the  amount  escaping,  and  where  the  fluid  thus  coming 
away  contains  but  a  small  amount  of  urine,  and  where  there  is  evi- 
dence that  the  other  kidney  is  competent,  I  think  an  attempt  should 
be  made  to  extirpate  from  the  loin  the  cyst  and  remaining  kidney 
tissue,  before  it  has  become  more  firmly  matted  to  the  surrounding 
parts.f 

iv.  Certain  cases  of  malignant  disease.  These  fall  into  two  groups, 
which  must  be  looked  at  separately  from  an  operative  point  of  view. 
One  group,  the  sarcomata,  occur  in  children  before  ten,  usually  much 
earlier,  before  five.  In  such  cases,  the  risks  of  immediate  death  from 
shock,  aided  often  by  peritonitis,  of  early  recurrence,  or  of  death  from 
secondar}'  deposits  elsewhere,  should  be  put  clearly  before  the  parents, 
together  with  the  certainty  of  an  early  death  if  the  growth  is  left. 

The  other  group,  the  carcinomafa,  occurs  usually  in  patients  j^ast 
middle  age.     Here  the  surgeon  will  be  aided  by  the  power  of  tlie  pa- 

*  As  made  by  Maw  &  Thompson. 

t  The  very  high  mortality  met  with  previously  in  nephrectomy  for  hydro-nephrosis 
— Dr.  Staples  (loc.  supra  cit )  gives  twenty-one  cases,  of  which  seventeen  were  treated 
by  laparotomy  with  eleven  deaths,  and  tliree  by  tlie  Inmbar  incision  with  one  death — is 
mainly  dne  to  extraction  of  large  kidneys  without  previous  drainage,  and  perhaps  in 
some  measure  to  the  errors  in  diagnosis,  by  which,  in  several  instances,  this  condition 
was  taken  to  be  an  ovarian  cyst. 

40 


626  OPERATIONS  ON  THE  ABDOMEN. 

tients  themselves  to  come  to  a  decision  after  the  risks  have  been  fully 
explained  to  them. 

In  either  case,  an  operation  sliould  only  be  performed  in  an  early 
stage,  while  the  growth  is  still  internal  to  the  capsule,  and  while  the 
strength,  health,  and  condition  of  the  viscera  are  satisfactory.  On  the 
other  hand,  where  the  history  makes  it  probable  that  the  growth  has 
got  beyond  the  earlier  stage,  Avhen  there  is  any  extension  to  the 
lumbar  glands  or  other  viscera,  when  there  is  nausea,  emaciation,  or  a 
temperature  inclined  to  fall,  the  time  for  operation  has  gone  by.  So, 
too,  any  ascites  or  oe<lema  of  the  lower  limb  are  absolute  contra-indi- 
cations.  With  regard  to  the  frequency  of  secondary  dej^osits,  it  is 
very  noteworthy  that  Dr.  Dickinson*  found  these  to  be  present  in  no 
fewer  than  15  out  of  19  cases  of  malignant  disease  of  the  kidney  in 
Avhich  post-mortem  examinations  were  made.*  This  seems  at  first 
sight  a  most  serious  objection  to  nephrectomy  in  malignant  disease 
of  the  kidney,  but  it  only  strengthens,  very  decisively,  the  argument 
in  favor  of  early  operations,  while  these  growths  are  small,  at  which 
time,  moreover,  they  can  be  successfully  attacked  through  a  lumbar 
incision  sufficiently  enlarged  by  the  steps  given  at  p.  631,  or  by  one 
made  anteriorly,  as  in  the  case  quoted  at  p.  638. 

A  recent  writer  on  the  subject  of  malignant  diseasef  thus  speaks  on 
the  question  of  operation  in  these  cases : 

"  The  death-rate  on  the  total  number  of  cases  is  enormously  large, 
more  than  60  per  cent.,  for  carcinoma  more  than  71  per  cent.  Nor  do 
I  think  that  a  study  of  the  causes  of  death,  whether  made  from  the 
paper  of  Gross  or  from  the  reports  of  the  individual  cases,  will  lead 
to  the  opinion  that  there  is  a  reasonable  prospect  of  largely  dimin- 
ishing it,  unless  the  diagnosis  of  the  disease  can  be  made  at  a  much 
earlier  period  than  it  has  been  hitherto. 

"  The  successful  cases  are,  I  am  sorry  to  say,  much  more  easily  dis- 
posed of  J  ....  For  the  operations  for  sarcoma  (from  which  fourteen 
survived)  ....  we  may  count  two  complete  cures  in  the  total  num- 
ber of  cases.  It  is  interesting  to  observe  that  not  one  instance  of  cure, 
or  even  of  long  relief,  is  recorded  in  the  cases  of  children. 

*  Dis  of  the  Ki  'ney,  and  Urinary  Derangements. 

t  Butlin,  Oper.  Surg,  of  Malig.  Dis.,  p.  254. 

X  Mr.  Butlin,  quoting  in  detail  from  Prof.  Gross  (Amer.  Journ.  Med.  ScL,  July, 
1885),  thus  specifies  the  results  in  the  cases  of  the  fourteen  survivors:  "One  died  of  an 
unknown  cause;  one  was  living  with  recurrence  at  the  end  of  four  months;  €ind  five 
died  of  the  disease  in  from  five  to  eighteen  months  of  the  operation ;  two  were  lost  sight 
of;  and  five  were  alive  and  well  at  the  end  of  seventeen,  twenty-two,  twenty-three, 
thirty-five  months,  and  five  years.  The  thirty-five  months  may  fairly  be  stretched  to 
three  years,  so  that  we  can  count  two  complete  cures  in  the  total  number  of  cases." 


NEPHRECTOMY.  627 

"  The  results  of  the  operations  for  carcinoma  are  even  viorse  than 
those  for  sarcoma.*  .... 

"  Of  the  eighteen  persons,  therefore,  who  recovered  from  the  opera- 
tion, only  two  can  be  regarded  as  cured ;  for  only  two,  both  of  whom 
had  suffered  from  sarcoma,  were  alive  and  well  at  the  end  of  three 
years  after  the  operation." 

The  following  conclusions  are  thus  drawn  by  Mr.  Butlin : 

"  Nei^hrectomy  for  the  removal  of  carcinoma  has  been  so  fatal  and 
so  thoroughly  unsuccessful  that  the  results  do  not  appear  to  justify  a 
continued  trial  of  the  operation. 

"  Nephrectomy  for  the  removal  of  sarcomatous  kidney  in  children 
has  not  been  so  fatal  as  for  carcinoma  in  adults ;  but  not  one  thor- 
oughly successful  result  can  be  claimed,  and  it  is  probable  that  the 
operation  will  fall  into  disrepute. 

"  Nephrectomy  for  sarcoma  of  the  kidney  in  adults  has  hitherto 
afforded  the  best  results,  but  the  successful  cases  are  so  few,  and  the 
mortality  is  so  large,  that  the  operation  is  not  likely  to  find  favor  in 
the  eyes  of  either  surgeons  or  their  patients." 

The  main  point  with  regard  to  future  treatment  here  appears  to  me 
to  be  this,  that  when  a  case  shows  signs  of  renal  malignant  disease — 
viz.,  a  steadily  growing  swelling  in  the  position  of  the  kidney,  with 
perhaps  haemorrhage  and  pain — the  doubt  should  be  early  cleared  up 
by  an  exploratory  lumbar  incision,  to  be  converted,  if  need  be,  into 
one  for  nephrectomy  by  the  additional  incisions  given  at  p.  631.  For 
such  cases  alone,  in  their  early  stage,  will  the  wise  surgeon  be  at  all 
inclined  to  urge  an  operation. 

Where  the  growth  is  already  larger,  and  the  patient  or  his  friends 
are  left,  as  they  should  be,  to  decide  the  matter  after  this  has  been 
explained  in  all  its  bearings,  the  surgeon  may  be  asked  as  to  what  resi- 
due of  life  may  be  expected  if  no  operation  is  performed.  In  answer 
to  this  question,  it  will  be  useful  to  remember  that  Dr.  Roberts  gives 
2J  years  as  the  average  duration  of  life,  without  operation,  in  adults. 
Dr.  Fagge,  speaking  of  carcinoma  in  adults,  states  that  the  average 
duration  of  life  is  "  probably  from  6  months  to  2  years  after  the  first 
appearance  of  symptoms." 

V.  Certain  cases  of  injury.  These  are  very  rare,  and  fall  into  the 
following  groups : 

(a)  Where  an  injured  kidney  protrudes  from  a  wound  of  the  ab- 
domen, usually  the  loin. 

(6)  In  some  cases  of  non-penetrating  wound  of  the  kidney,  as  when 
it  is  ruptured  from  a  fall  or  blow. 

*  ''  Four  patients  recovered  from  the  operation,  of  whom  two  died  of  secondary 
growths  within  two  months  of  their  recovery ;  one  was  alive  and  well  at  the  end  of 
two  months,  the  other  at  the  end  of  thirteen  months." 


628  OPERATIONS  ON  THE  ABDOMEN. 

(1)  Where  there  is  haematuria  which  does  not  yield  to  treatment,* 
the  bleeding  being  well  marked,  or  latent  and  insidious,  giving  evi- 
dence indirectly  of  its  existence,  by  the  increasing  pallor,  the  failing 
pulse,  impending  syncope,  and  perhaps  swelling  in  the  loin. 

(2)  Later  on,  when  the  injured  kidney  is  setting  up  serious  suppu- 
ration, which  does  not  yield  to  nephrotomy  and  drainage,  or  where, 
during  an  exploratory  nephrotomy,  the  injury  to  the  kidney  is  found 
to  be  very  severe,  e.g.,  a  transverse  rent. 

(3)  For  ruptured  ureter.  Mr.  Barker  has  recordedf  a  most  suc- 
cessful case,  in  which,  after  other  treatment  had  failed,  he  removed  a 
kidney  three  months  after  the  rupture.  The  child,  aged  three  and 
a  half,  had  been  run  over,  but  beyond  some  bruising  and  one  small 
clot  passed  there  was  nothing  to  point  to  injury  of  the  urinary  tract. 
Having  left  the  hospital  in  a  fortnight,  apparently  convalescent,  he 
was,  a  few  days  later,  admitted  with  a  fluctuating  swelling  in  the  right 
loin.  This  increasing,  was  aspirated,  the  fluid  yielding  h  per  cent,  of 
urea.  The  swelling  was  subsequently  drained,  and  the  drainage-tube 
becoming  blocked  with  phosphatic  deposits,  and  thus  causing  a  good 
deal  of  constitutional  disturbance,  the  kidney  was  removed.  It 
proved  to  be  healthy,  the  ureter  being  torn  across  just  below  it. 

(c)  Penetrating  wounds. 

Very  rarely  indeed  nephrotomy  may  be  called  for  here  when 
haemorrhage  does  not  yield  to  treatment  aided  by  exploration  and 
plugging. 

When  a  urinary  fistula  persists  after  such  a  wound  in  certain 
cases — e.g.,  when  the  other  kidney  is  healthy. 

(d)  Gunshot  wounds. 

Owing  to  the  increase  of  revolver-injuries  and  recent  advances  in 
abdominal  surgery,  this  matter  has  lately  received  much  attention.^ 

Whether  in  civil  or  military  practice,  gunshot  wounds  of  the 
kidney  are  only  too  likely  to  be  complicated  with  injuries  of  the  intes- 

*  In  Mr.  Kawdon's  case  [he.  infra  cit.)  nephrectomy  was  performed  for  hsemorrhage 
after  an  injury,  but  at  rather  a  later  date — e.g ,  on  the  seventeenth  day  after  the  fall — 
to  prevent  blood  from  entering  the  bladder  and  increasing  the  acute  cystitis  present. 
Here  the  hsematuria  had  diminished  at  first,  and  then  subsequently  increased. 

t  Lancet,  January  17,  1885. 

J  As  might  be  expected,  American  surgeons  have  not  been  slow  to  avail  themselves 
of  (heir  opportunites.  Prof.  Nancrede  (Annals  of  Surgery,  June,  1887,  p.  480)  suggests 
that  when!  the  renal  or  splenic  artery  is  cut  by  a  bullet,  the  viscus  should  be  removed, 
as  gangrene  is  inevitable.  He  further  states  that  Dr.  Keen  has  removed  a  kidney  for 
uncontrollable  hseraorrhage  following  gunsiiot  injury.  Dr.  Parkes  {loc.  supra  cit-, 
November,  1887,  p.  379),  in  a  case  of  bullet-wound  of  the  abdomen,  having  sewn  up 
live  perforations  of  the  intestine,  found  that  the  left  kidney  was  perforated.  The 
haemorrhage  was  very  slight  at 'this  time.  After  doing  well  for  twenty-four  hours, 
the  patient  began  suddenly  to  fiiil,  and  died  collapsed  from  hsemorrhnge  from  the 
kidney.     Dr  Parkes  regretted  that  he  had  not  performed  nephrectomy. 


NEPHRECTOMY.  629 

tines,  liver,  and  spine.  When  in  the  course  of  an  exploratory  opera- 
tion in  the  case  of  a  gunshot  wound  of  the  abdomen,  the  kidney  is 
found  to  be  the  seat  of  ha^'morrhage,  uncontrollable  by  other  means, 
nephrectomy  should  be  performed. 

(e)  In  a  few  cases  of  nephrorraphy. 

Where,  after  nephrorraphy,  the  mobility  of  the  kidney  is  not  much 
diminished,  still  less  abolished  ;  where  there  is  much  real  pain, 
nausea,  inability  to  carry  out  the  duties  of  life,  nephrectomy  may  be 
resorted  to  if  the  condition  of  the  opposite  kidney  admits  of  it.  In  a 
small  class  of  cases  nephrorraphy  will  be  found  to  fail,  owing  to  the 
intervention  of  organic  disease,  as  in  the  instance  given  at  p.  644. 

Operations. 

Three  will  be  described  here. 

A.  Through  the  Lumbar  Region. 

B.  Through  the  Abdominal  Wall  and  the  Peritoneum  as 
well. 

(a)  By  an  incision  at  the  outer  edge  of  the  rectus. 

(b)  By  one  in  the  linea  alba. 

C.  Through  the  Abdominal  Wall,  without  opening  the 
Peritoneum. 

These  methods  are  compared  at  p.  639. 

A.  Lumbar  Nephrectomy. 

Operation, 

The  position  *  of  the  ]>atient  and  the  earlier  steps  are  much  as  those 
already  given  in  the  account  of  Nephro-lithotomy,  p.  614. 

When  the  lumbar  fascia  has  been  slit  up  and  the  fat  around  the 
kidney  torn  tlirough,  th^'s  organ  should  be  well  thrust  up  by  an 
assistant  making  careful,  steady  pressure  with  his  fist  against  the 
abdominal  wall :  the  wound  being  now  widely  dilated  with  re- 
tractors, the  surgeon  examines  the  kidney,  and  has  next  to  decide  on 
three  points  : 

(1)  Is  removal  required?! 

(2)  Will  more  room  be  wanted  ?  If  so,  the  incision  already  made 
slightly  oblique  and  about  j  inch  below  the  twelfth  rib,  should  be 

*  Additional  care  should  be  taken  to  open  out  the  space  between  the  last  rib  and 
the  crest  of  tJie  ilium  by  the  arrangement  of  pillows  underneath  the  loiu,  and  pre- 
cautions must  be  taken  here  to  avoid  shock — e.ff.,  bandaging  the  limbs  in  cotton-wool, 
having  only  the  site  of  the  wound  expose<l,  keeping  the  head  low,  having  injections 
of  brandy  or  whisky  ready,  and  giving  ether  instead  of  chloroform.  If  the  condition 
of  the  patient  is  low,  the  spray  had  better  be  dispensed  with,  and  an  assistant  told  off 
to  occasionally  irrigate  the  wound  with  a  solution  of  mercury  perchloride,  glycerine, 
and  water  (1  in  lOUO). 

f  This  question  has  already  been  alluded  to  in  the  case  of  a  strumous  kidney  in- 
cised and  drained  (p.  623) ;  in  that  of  a  kidney  nnich  damaged  by  one  or  more 
calculi,  under  the  subject  of  Nephro-lithotomy  (p.  620) ;  and  in  the  case  of  hydro, 
nephrosis  'p.  624). 


630  OPERATIONS  ON  THE  ABDOMEN. 

converted  into  a  T-shaped  one  by  another  made  downwards  from  its 
centre,  or  at  its  posterior  extremity,  along  the  outer  edge  of  the 
quadratus  lumborum.  Additional  room  may  also  be  gained  by  an 
assistant  slipping  his  hand  under  the  lower  ribs  and  drawing  them 
forcibly  upwards. 

(3)  Is  the  kidney  firmly  matted  down  or  no?  If  there  has  been  no 
surrounding  inflammation,  the  extra-peritoneal  fat,  the  peritoneum, 
and  colon  will  be  readily  separated  by  the  finger  working  close  to 
the  kidney  until  the  pelvis  and  vessels  are  reached.  But  if  inflam- 
mation has  caused  firm  adhesion  and  matting  down  of  the  kidney  to 
adjacent  parts,  the  altered  fat  and  thickened  and  adherent  capsule 
must  be  divided  down  to  the  kidney  itself,  and  this  gradually  enu- 
cleated (partly  with  the  finger,  partly  with  a  probe-pointed  bistoury) 
from  out  of  its  capsule  which  is  left  behind. 

The  only  guide  in  such  a  case  is  the  tissue  of  the  kidney  itself, 
close  to  which  the  finger  and  knife  must  be  kept. 

A  case  of  Mr.  H.  Marsh's  well  shows  this  difficult3^  On  exploring 
a  kidney,  the  site  of  pyelitis,  probabl}'-  tubercular,  and  stripping  off 
the  capsule  from  the  part  of  the  organ  which  presented,  the  kidney 
was  incised,  giving  vent  to  much  foetid  pus.  The  organ  was  now 
found  to  be  so  extensively  diseased  as  to  require  removal.  Its  enu- 
cleation could  not,  however,  be  effected,  owing  to  the  size  of  the 
kidney  and  the  firmness  with  which  it  was  embedded  in  the  sur- 
rounding, condensed  areolar  tissue.*  That  part  of  the  kidney  which 
had  been  exposed  was  accordingly  transfixed  with  a  strong,  double 
ligature,  and  cut  away.  Complete  suppression  of  urine  f  followed 
the  operation,  and  the  patient  died  in  about  thirty  hours. 

At  the  post-mortem  examination  the  remaining  part  of  the  right  kid- 
ney and  its  ureter  were  so  firmly  embedded  in  dense  cicatricial  material 
that  they  were  dissected  out  only  with  difficulty.  The  kidney  itself 
was  converted  into  numerous  sacculi,  in  the  walls  of  which,  however, 
some  remains  of  renal  structure  could  still  be  traced.  The  opposite 
kidney  weighed  6  ozs.  Its  capsule  was  adherent,  and  there  were  two 
or  three  smull  cysts  on  its  surface.     On  section,  its  structure  looked 

*  Mr.  Marsh,  in  his  remarks  on  this  case  (Clin.  Soc.  Trans.,  vol.  xv.  p.  142),  points 
out  that  the  state  of  tlie  kidney  liere  proved  to  be  much  worse  than  there  liad  seemed 
reason  to  anticipate.  AUhongh  it  had  been  impossible  to  feel  it  in  a  very  careful 
examination  under  ether,  it  was  dilated  to  a  very  large  size.  Mr.  Marsh  further 
thinks  "  it  very  doubtful  whether  it  will  not  ultimately  be  found  that  the  safest  way 
of  removing  the  kidney  is  by  abdominal  section  through  an  incision  just  external  to 
the  rectus,"  as  "the  lumbar  incision  does  not  aff'ord  sufficient  space  for  the  removal  of 
a  kidney  of  large  size,  or  of  one  that  is  firmly  bound  down  by  adhesions."  It  is  not, 
however,  stated  whether  the  lumbar  incision  made  use  of  by  Mr.  Marsh,  "an  oblique 
incision  in  the  loin,"  was  prolonged  forwards  freely  (p.  631),  and  still  further  room 
given  by  converting  it  into  a  T  incision. 

t  The  urine  had  been  horribly  foetid,  and  the  sp.  gr.  never  above  1015. 


NEPHRECTOMY.  631 

somewhat  confused  and  cloudy,  but  its  condition  was  not  such  as  to 
indicate  advanced  disease. 

Mr.  Greig  Smith  draws  attention*  to  the  fact  that,  in  cases  of  ohl- 
standing  suppuration  with  great  enlargement,  the  vena  cava  and  the 
aorta  ma}^  be  intimatel}'  adherent  to  the  capsule.  "  One  such  case 
was  recentl}'  met  with  in  the  post  mortem  room  of  the  Bristol  Infirm- 
ary ;  here  it  was  simply  impossible,  after  death,  to  dissect  apart  the 
venous  wall  and  the  renal  capsule.  In  another  case,  for  similar 
reasons,  the  organ  could  not  have  been  removed  by  any  proceeding 
claiming  to  be  recognized  as  surgical." 

If  further  room  is  still  required,  this  may  be  easily  and  effectually 
gained  by  making  use  of  additional  incisions  as  recommended  by 
Prof.  Konig,t  of  Gottingen.  This  surgeon,  having  found  great  diffi- 
culty in  getting  free  access  to  the  kidney  by  the  ordinary  lumbar 
incision,  cuts  through  the  soft  parts  vertically  downwards  along  the 
border  of  the  rector  spinee  to  just  above  the  iliac  crest.  He  then 
curves  round  anteriorly  towards  the  navel,  and  ends  at  about  the 
outer  border  of  the  rectus,  if  necessary  going  through  this  muscle  to 
the  umbilicus.  It  may  be  often  advisable  to  make  the  perpendicular 
cut  oblique,  running  in  a  flat  curve  into  the  umbilical  part.  All  the 
muscles  are  incised  quite  down  to  the  peritoneum.  This  method  gives 
a  surprisingly  free  entrance,  but  it  can  be  much  improved  by  intro- 
ducing the  hand  through  the  perpendicular  part  of  the  cut,  separating 
the  peritoneum  in  front  and  pushing  it  forwards.  Prof.  Konig  pro- 
poses to  call  this  the  retro-peritoneal  lumbo-abdominal  incision.  If 
sufficient  space  is  not  thus  afforded,  or  if  for  diagnostic  or  operative 
purposes  it  is  desirable  to  approach  the  tumor  from  the  abdominal 
cavity,  the  peritoneum  can  be  divided  in  the  transverse  cut.  If  in- 
fectious material  is  to  be  removed,  this  peritoneal  opening  must  be 
carefully  looked  after.  Two  recent  cases  are  given  illustrating  the 
second  method.  (1)  Old  i3yelo-nephrosis,  with  a  colossal  calculus  in 
the  pelvis.  The  removal  of  the  stone  was  only  possilile  by  the 
additional  peritoneal  opening.  (2)  Vesical  catarrh  with  stinking 
pyelitis.  Cure  took  place  in  both  cases,  excepting  slight  remaining 
fistulfB. 

The  danger  of  ventral  hernia  is  guarded  against  by  using  deep 
sutures,  by  allowing  only  gentle  movements  after  the  patient  gets  up, 
and  by  the  use  of  a  support.     In  this  way  hernise  do  not  result.^ 

*  Abdom.  Surg.,  p.  508. 

t  Cent./.  Chir.,  1886,  No.  35;  Annah  of  Surgery,  November,  ISSfi.  p.  445. 

X  It  is  noteworthy  that  Prof.  Bergmann,  of  Berlin,  whose  name  is  well  known  in 
connection  with  the  surgery  of  the  urinary  organs,  advocates  the  lumbar  operation 
for  the  removal  of  malignant  growths  of  the  kidney  {Annals  of  Surgery,  September, 
1886,  p.  256). 


632  OPERATIONS  OX  THE  ABDOMEN. 

Wlien  the  kidney  has  been  sufficiently  enucleated  either  out  of  its 
cai)sule,  or,  together  with  this,  out  of  the  peri-renal  fat,  the  vessels 
and  ureter  must  be  dealt  with.  The  latter  should  be  taken  first,  as 
this  step,  especially  if  the  ureter  be  enlarged,  will  facilitate  dealing 
with  the  vessels. 

If  the  ureter  is  dilated,  and  contains  foul  pus  or  tubercular  matter, 
the  stump  should  be  carefully  cleaned  out  with  a  sharp  spoon  and 
dusted  with  iodoform,  or  brought  up  into  the  wound  with,  and 
retained  there  by,  a  suture,  for  fear  of  its  infecting  the  wound. 

The  vessels  are  then  tied  in  at  least  two  bundles  with  sufficiently 
stout  carbolized  silk.'^  This  is  passed,  with  an  aneurism-needle  ot 
sufficient  length  and  suitable  curve,  through  the  centre  of  the  bundle, 
each  half  of  which  is  tied  separately,  and  finally  one  of  the  ligatures 
is  thrown  round  the  two  halves  together.  In  passing  the  ligatures, 
they  should  be  pushed  well  in  towards  the  spine,  so  as  to  leave  suffi- 
cient room  between  them  and  the  kidney  to  prevent  all  risk  of  their 
slipping.  If  the  kidney  can  be  raised  out  of  the  wound,  passing  the 
ligature  is  much  simplified.  If  this  is  impossible,  the  surgeon  may 
find  help  by  having  the  lower  limbs  well  pulled  up  by  an  assistant, 
while  another  keeps  the  kidney  well  up  by  pressure  against  the  ab- 
dominal walls,  light  being  also  thrown  in,  in  case  of  need,  by  a  laryn- 
geal mirror.  While  the  ligatures  are  being  tied,  or  in  dividing  the 
pedicle,  no  tension  should  be  put  ui)on  them. 

As  soon  as  the  ligatures  are  securely  in  position,  the  pedicle  is 
snipped  through  at  a  safe  distance  from  them  with  blunt-pointed 
scissors.  If  the  pelvis  of  the  kidney  contains  foul  or  tubercular  pus, 
and  if  there  is  room,  a  large  pair  of  Spencer  Wells'  forceps  should  be 
put  on  the  pelvis,  and  the  pedicle  cut  through  between  this  and  the 
ligatures,  so  as  to  prevent  escape  of  septic  material.  These  last  are 
then  cut  short.  If  any  haemorrhage  now  takes  place,  it  is  probably 
due  to  some  vesself  not  being  included,  or  an  artery  having  slipped 
through  the  knot  owing  to  the  parts  being  stretched  at  the  moment  of 
ligature.     In  the  event  of  attempts  to  arrest  such  hismorrhage  by 

*  See  foot-note,  p.  404 

f  Mr.  Greig  Smith  (loc.  svpra  cit.)  gives  tlie  following  practical  hints  as  to  the 
vessels  :  The  veins  are  a  good  deal  larger  than  the  arteries,  and  overlap  them.  At 
the  hihim  tlie  veins  hranch  quite  as  much  as  the  arteries— i.e.,  fonr  or  five  times — 
and  the  subdivision  extends  farther  towards  the  niiildle  line.  It  is  very  frequent  for 
two  or  more  trunks  to  represent  the  renal  vein,  and  sometime  surround  the  artery. 
The  want  of  uniformity  in  the  renal  vessels  is  against  the  possibility  of  ligaturing  the 
artery  and  vein  separately.  In  many  cases  this  will  be  found  impossible;  in  none 
is  it  necessary.  Indeed,  the  walls  of  the  veins,  by  acting  as  a  sort  of  padding,  may 
add  to  the  safety  of  ligatures,  preventing  the  thread  from  slipping.  Mr.  Greig  Smith 
further  states  that  the  only  deaths  as  yet  recorded  from  secondary  haemorrhage  were 
in  two  cases  where  the  vessels  were  separately  tied. 


NEPHRECTOMY.  633 

ligature  foiling,  it  must  be  stopped  by  applying  Spencer  Wells's  for- 
ceps and  leaving  them  in  situ,  or  by  firm  plugging  with  aseptic  gauze 
dusted  with  iodoform. 

When  a  pedicle  presents  especial  difficulties  from  its  shortness, 
thickness,  and  the  way  in  which  it  is  overlapped  by  the  kidney,  a 
preliminary  ligature  should  be  applied  and  the  kidney  cut  away  well 
in  front  of  it,*  a  step  which  will  give  access  to  the  vessels  and  ureter  ; 
a  double  ligature  is  then  applied  behind  the  temporary  ligature,  which 
is  now  removed. 

A  modification  of  the  above  method  of  leaving  a  portion  of  the 
kidney  to  form  the  pedicle  may  be  made  use  of  in  cases  of  kidneys  of 
large  size  which  cannot  be  brought  through  the  wound.  In  such 
cases,  the  vessels  being  secured  by  a  temporary  ligature  or  by  a 
Spencer  Wells'  forceps,  tlie  kidney  should  be  cut  away  in  separate 
portions,  thus  doing  away  with  the  struggle  required  in  bringing  out 
a  large  kidney  and  the  risks  of  producing  serious  shock  by  pulling  on 
the  vessels. t 

By  the  above  methods  the  risk  of  wounding  the  cava  or  aorta  is 
avoided.  If  the  amount  of  kidney  left  is  small,  it  will  no  doubt 
atrophy  and  give  no  further  trouble,  but,  if  large,  some  sloughing  will 
probably  take  place ;  in  such  a  case  iodoform  should  be  dusted  on  to 
the  stump  and  free  drainage  provided. 

Another  difficulty  which  may  be  present  now  is  caused  by  the 
kidney  having  contracted  adhesions  to  the  peritoneum  and  some  of 
its  contents.  Thus  in  a  case  in  which  Mr.  Adams  removed  a  carci- 
nomatous kidney  by  lumbar  nephrectomy,  in  separating  the  adhesions 
the  peritoneal  cavity  was  opened  and  the  thin  free  edge  of  the  liver 

*  Dr.  Lange  (New  York  Surg.  Soc,  November  22,  1886  ;  Aitnals  of  Surgery,  April, 
1887)  has  .«lio\vii  tliat  in  a  case  in  wliicli  lie  adopted  this  course  no  slougliing  took 
place,  as  the  thick,  fehy  part  of  the  pedicle  beyond  the  ligatures  was  gradually  ab- 
sorbed by  the  healthy  granulations  of  the  wound,  which  remained  aseptic.  Dr.  Leopold 
(Arch,  fib-  Gyndk.,  xix.  1),  in  a  case  of  nephrectomy,  tied  the  pedicle  in  three,  and  left 
a  triangular  portion  of  the  kidney  parenchyma,  in  order  to  prevent  hfemorrhage.  The 
patient  made  a  good  recovery. 

t  The  question  of  how  far  serious  shock  may  be  induced  by  tightening  ligatures  on 
parts  in  such  intimate  relation  with  the  abdominal  sympathetic  centres  is  one  of  great 
importance,  and  needs  further  investigation.  According  to  Mr.  Barker  {Dirt,  of  Surg., 
vol.  ii.  p.  49),  who  has  taken  the  trouble  to  have  the  pulse  watched  carefully  at  this 
stage  of  the  operation,  it  is  not  much  affected  to  the  touch,  but  a  sphygmographic 
tracing  taken  in  one  case  showed  some  irregularity  during  the  necessary  handling  of 
the  kidney,  and  increased  arterial  tension  when  the  pedicle  was  ligatured.  But 
whether  or  no  these  observations  are  confirmed  in  the  future,  it  is  certain  that  all 
manipulations  of  an  organ  like  the  kidney  cannot  be  too  carefully  carried  on,  especially 
towards  the  close  of  a  difficult  nephrectomy. 


634  OPERATIONS  ON  THE  ABDOMEN. 

exposed.*  The  wound  in  the  peritoneum  was  closed  with  fine  catgut 
sutures,  and,  in  spite  of  a  very  troublesome  cough,  the  patient  made 
a  good  recovery  from  the  operation,  dying  forty-four  days  later  from 
malignant  deposits  in  the  chest-wall,  opposite  kidney,  and  lumbar 
glands  {Clin.  Soc.  Trans.,  vol.  xv.). 

If  before  or  after  ligature  of  the  pedicle  there  is  still  much  difficulty 
in  getting  a  large  kidney  through  the  wound  (though  if  the  aids  already 
given  are  followed — viz.,  making  the  first  incision  into  a  T,  dragging 
up  the  ribs,  prolonging  the  horizontal  or  oblique  incision  well  forward, 
and  separating  the  peritoneum  forwards  also — a  great  increase  of  space 
will  be  given),  the  surgeon  may  follow  the  example  of  Mr.  Barwell,t 
who,  in  a  case  of  nephrectomy  calling  urgently  for  completion  owing 
to  the  haemorrhage,  obtained  the  necessary  room  for  reaching  the 
pedicle  by  partially  breaking  up  the  gland,  and  next,  having  tied  the 
pedicle,  cut  the  gland  in  two  towards  the  ligature,  and  then,  verifying 
bloodlessness,  severed  each  half  from  the  pedicle  and  removed  them 
separately. 

The  pedicle  being  secured  and  cut  through  at  a  safe  distance  from 
the  ligatures  with  blunt-pointed  scissors,  the  surgeon  should  examine 
for  any  bleeding  point,J  to  which  the  ligatures  already  in  place  will 
act  as  a  guide.     When  all  bleeding  is  stopped,§  a  large  drainage-tube 

*  In  a  case  of  attempted  nephrectomy  (Amer.  Jnurn.  Med.Sci.,  1882,  vol.  ii.  p.  116} 
the  removal  of  the  organ  was  rendered  impossible,  not  only  by  its  adhesions  to  the 
tissues  around,  but  also,  as  was  proved  post  mortem,  to  the  colon  and  pancreas  as  well, 

f   Trcms.  Intern.  Med  Congr.,  vol.  ii.  p.  276. 

X  This  may  be  due  to  the  renal  vessels  breaking  up  into  a  larger  number  of  branches 
than  usual,  or  to  some  abnormal  vessel.  Dr.  Lange,  of  New  York  {Annals  of  Surgery, 
October,  1885,  p.  297),  in  several  bodies  found  a  rather  tliick  venous  branch  coming 
from  below,  beiiind  the  pelvis  and  ureter,  and  entering  intoabranch  of  the  renal  vein, 
which  took  origin  abnormally  from  the  renal  substance  on  a  level  behind  the  pelvis. 
Dr.  Lange  suggests  that  this  vessel  may  have  been  a  spermatic  vein,  but  was  unable 
to  verify  this  point. 

^  The  question  may  arise  as  to  what  is  to  be  done  if  haemorrhage  still  persist  after 
the  kidney  is  got  out,  and  its  pedicle  tied.  Very  few  cases  will  occur  in  which  liga- 
tures cannot  be  applied  to  each  bleeding  point  if  the  wound  be  well  opened  up,  care- 
fully dried,  and  light  thrown  down  to  the  bottom.  But  if  bleeding  still  goes  on,  either 
Spencer  Weils'  forceps  must  be  applied  to  the  bleeding  point  and  left  in  situ  for  two  or 
three  days,  during  which  they  will  also  help*  to  drain  the  wound,  or  careful  plugging 
must  be  resorted  to,  strips  of  iodoform  or  sal-alembroth  gauze  or  carbolized  sponges 
(the  deepest  attached  to  silk)  being  systematically  {jacked  into  the  bottom  of  the  wound 
around  a  large  drainage-tube  till  the  wound  is  thoroughly  filled;  an  external  gauze 
dressing  is  then  applied,  and  over  this  a  firm  but  elastic  padding  of  sal-alembroth 
wool,  which  is  kept  in  situ  by  firm  bandaging.  Mr.  Clement  Lucas  {Trans.  Intern. 
Med.  Congr.,  vol.  ii.  p.  271)  nearly  lost,  from  secondary  htemorrhage,  a  case  in  which 
nephrectomy  had  been  successfully  performed  for  suppurating  strumous  pyelitis.  This 
was  brought  on  about  the  fifteenth  day,  probably  from  the  ligatures  which  had  been  left 
long  being  dragged  upon.   The  hemorrhage  again  occurred  on  the  sixteenth  day,  when 


NEPHRECTOMY.  635 

should  be  inserted,  with  one  end  carried  down  to  the  very  bottom  of 
the  wound  and  the  other  cut  ahiiost  flush  with  the  surface.  The  wound 
is  then  accurately  closed  Avith  silver-wire  and  carbolized-silk  sutures, 
some  iodoform  dusted  on,  and  aseptic  dressings  applied. 

Dr.  Weir,  of  New  York  (Ann.  of  Surg.,  April,  1885,  p.  311),  during 
a  case  of  nephrectomy  in  a  young  woman  the  subject  of  pyo-nephrosis, 
met  with  very  severe  haemorrhage  after  ligature  of  the  pedicle.  This 
had  apparentl}^  been  effected  with  a  single  ligature.  After  removing 
the  kidney,  a  gush  of  venous  blood  ensued,  which  was  only  partly 
arrested  after  repeated  seizures  with  long  forci-pressure  forceps,  but 
was  finally  controlled  by  stuffing  the  wouno  full  of  sponges  and  turn- 
ing the  patient  on  her  back.  The  shock  was  profound,  and  all  the 
measures  to  produce  reaction  were  resorted  to,  such  as  heat,  stimulants, 
the  application  of  Esmarch's  bandages  to  the  limbs,  and  saline  trans- 
fusion. The  latter,  repeated  twice  to  a  total  amount  of  22  oz.,  gave 
rise  at  first  to  great  improvement  in  consciousness,  pulse,  and  warmth 
of  body ;  for  a  while  the  patient  appeared  to  rally,  but  she  died  ten 
hours  after  the  operation.  The  autopsy  showed  that  the  haemorrhage 
came  from  a  vein  of  considerable  size,  1.5  centimeter  above  those  se- 
cured by  the' ligature  and  forceps. 

B.  Nephrectomy  by  Abdominal  Incision  through  the 
Peritoneum. 

(I.  By  Langenbeck's  Incision  at  the  Outer  Edge  of  the 
Rectus. 

b.  By  an  Incision  in  the  Linea  Alba. 

These  two  methods  may  be  taken  together.  The  former  is  the  one 
most  usually  emploj^ed,  as  it  has  the  following  great  advantages : 

1.  The  incision  is  nearer  the  vessels  and  ureter. 

2.  There  is  much  less  general  exposure  of  the  peritoneal  cavity.* 

3.  The  kidney  is  reached  through  the  outer  or  posterior  layer  of  the 
meso-colon,  a  step  which  avoids  (a)  hsemorrhage  and  (6)  the  risk  of 
sloughing  of  the  colon,  as  it  is  the  inner  or  anterior  layer — that  between 
the  colon  and  the  middle  line — which  contains  most  of  the  vessels  to 
the  colon,  this  layer  being  especially  rich  in  veins.  It  is  this  layer 
which  is  divided  in  the  incision  through  the  linea  alba. 

4.  The  operation  can  be  render«ed  largel}^  extra-peritoneal  by  having 

an  attempt  was  made,  after  opening  up  the  wound,  to  slip  a  ligatnre  along  the  old  ones, 
and  thus  to  re-tie  the  pedicle.  Haemorrhage  again  occurring  on  the  seventeenth  day,  and 
the  patient  being  in  a  niost  precarious  state,  the  wound  was  tightly  and  forcibly  plugged 
witij  two  large  sponges  steeped  in  perchloride  of  iron,  and  the  abdomen  bound  firmly 
round  with  a  flnnnel  bandiige.  Morphia  was  given  subcutaneously.  About  a  week 
later  the  removal  of  the  sponges,  by  cutting  away  the  protruding  part,  was  commenced, 
and  this  was  completed  by  the  end  of  another  week.  No  bleeding  recurred  after  the 
}ilugging,  and  the  patient  made  a  good  recovery. 
*  Knowsley  Thornton. 


G36  OPERATIONS  OX  THE  ABDOMEN. 

the  inner  edge  of  the  cut  meso-colon  and  tluit  of  the  parietal  peritoneum 
held  in  apposition  or  sutured  with  catgut. 

Both  operations  give  good  room  for  necessary  manipulations,  both 
afford  an  opportunity  for  examining  with  the  hand  the  condition  of 
the  opposite  kidney.*  After  both  the  wound  can  be  drained,  poste- 
riorly, from  the  loin,  but  more  easily  after  Langenbeck's  incision. 

a.  Langenbeck's  Incision. — The  abdominal  wall  l)eing  cleansed, 
an  incision  is  made,  at  least  4  inches  long  to  commence  with,  in  the 
line  of  the  linea  semilunaris  on  the  side  of  the  disease,  the  centre  of 
the  incision  being  usually  opposite  to  the  umbilicus.  The  structures, 
skin,  subcutaneous  tissue,  and  the  aponeurosis  at  the  outer  edge  of  the 
rectus  being  divided  down  to  the  tran^versalis  fascia,  all  htemorrhagef 
being  carefully  arrested,  the  transversalis  fascia  and  peritoneum  are 
pinched  up  together,  punctured,  and  slit  up  on  a  finger  used  as  a  di- 
rector, the  hand  is  introduced,  and  the  size  of  the  growth  and  the 
condition  of  the  opposite  kidney  investigated.  In  the  case  of  a  large 
growth,  the  incision  will  now  be  enlarged,  and  any  further  haemor- 
rhage arrested.  The  growth,  if  large,  is  usually  now  seen  in  part.  Any 
presenting  intestine  is  turned  over  to  the  opposite  side,  and  kept  out 
of  the  way  with  a  soft  flat  sponge.  The  outer  or  posterior  layer  of  the 
meso-colon  will  now  probably  present  itself  pushed  forward  by  the 
growth,  which  is  often  bluish-white  in  appearance,  and  covered  by  large 
veins.  The  above-mentioned  layer  of  the  meso-colon  is  next  torn 
through,  either  in  a  vertical  or  transverse  direction  as  will  best  avoid 
the  vessels  exposed.  Any  bleeding  should  be  at  once  arrested  by 
Snencer  Wells'  forceps  and  ligatures  of  chromic  gut  or  fine  carbolized 
silk. 

A  sufficient  opening  being  made  in  the  meso-colon,  the  fingers  are 
introduced  to  examine  into  and  further  separate  the  connections  of 
the  kidney. 

During  all  the  necessary  manipulations  in  the  case  of  a  growth,  the 
greatest  possible  gentleness  must  be  used  so  as  not  to  rupture  the  cap- 
sule. In  rapidly  growing  sarcomata,  especially  in  children,  the  con- 
sistency may  be  jelly-  or  glue-like,  and  thus,  if  the  capsule  is  opened, 


*  I  cannot  but  think  that  this  advantage  of  the  incisions  tlirongh  the  peritoneum 
has  been  made  too  inuch  of.  In  Mr.  Barker's  words  {Diet,  of  Surg.,  vol.  ii.  p.  48), 
"  tliough  tlie  hand  may  reacli  the  kidney  opposite  to  tlie  one  it  is  proposed  to  excise, 
its  soundness  or  the  reverse  cannot  be  ascertained  by  mere  palpation.  Great  enlarge- 
ment, or,  on  the  other  hand,  great  reduction,  in  size,  or  complete  absence,  might  be 
detected;  but  the  organ  might  be  tubercular,  or  fibroid,  or  contain  a  moderate-sized 
calculus,  and  yet  the  hand  be  unable  to  detect  the  condition  " 

f  The  amount  of  this,  as  will  be  familiar  to  all  surgeons  who  have  opened  the  peri- 
toneal cavity  by  this  incision  for  intestinal  obstruction,  intussusception,  etc.,  varies  a 
good  deal. 


KEPHRECTOMY.  637 

portions  of  the  growth  may  easily  be  left  behind.  Again,  haemorrhage 
may  easily  follow  this  accident,  and  prove  most  embarrassing.* 

The  same  precautions  as  to  not  damaging  the  capsule  should  be 
taken  in  the  case  of  a  kidney  full  of  fluid.  Where  there  is  any  risk  of 
such  fluid  or  of  soft  growth  being  spilt  into  the  peritoneal  cavity, 
sponges  (duly  counted)  should  be  carefully  packed  around,  or  the  cut 
edges  of  the  meso-colon  and  the  parietal  peritoneum  united  (p.  636). 

The  kidney  being  sufficiently  isolated,  the  ureter  is  first  tied  and 
divided;  the  vessels  are  then  found,  and  divided  with  the  precautions 
already  given  (p.  632).  All  dragging  on  the  pedicle  should  be  most 
scrupulously  avoided. 

The  kidney  being  removed,  the  site  of  the  operation  is  most  care- 
fully cleansed  and  dried.  If  troublesome  oozing  has  occurred  and  is 
at  all  likely  to  persist,  a  large  drainage-tube  had  best  be  passed  out 
through  the  loin  by  pushing  a  short  pair  of  dressing-forceps  from  the 
site  of  the  kidney  so  that  it  bulges  in  the  loin,  Avhere  it  is  cut  down 
on,  and  drags  through,  the  tube.  If  the  patient's  condition  admits  of 
it,  the  divided  edges  of  the  meso-colon,  if  not  already  dealt  with,  may 
be  united  with  a  few  points  of  catgut  suture,  but  this  precaution  does 
not  seem  to  be  absolutely  needful,  as  they  usualh' fall  readily  into 
apposition. 

Mr.  K.  Thornton's  suggestion  to  bring  the  ureter,  where  this  is  in  a 
septic  condition,  as  in  pyonephrosis,  up  into  and  to  fix  it  in  the 
wound  seems  not  unlikely  to  risk  the  occurrence  of  future  intestinal 
obstruction,  by  raising  up  a  band  between  the  pelvis  and  the  abdominal 
wall.  It  would  seem  far  preferable  to  bring  it  out,  if  the  stump  cannot 
be  disinfected  after  ligature,  through  the  loin  by  a  counter-puncture 
here. 

h.  Nephrectomy  by  an  Incision  in  the  Linea  Alba.— For 
reasons  already  given,  p.  635,  this  method  is  not  recommended,  that 
of  Langenbeck,  already  fully  described,  being  preferred. 

The  incision  in  the  linea  alba  will  not  materially  differ  from  that 
for  ovariotomy  or  abdominal  exploration,  i^p.  654,  and  the  same  pre- 
cautions are  called  for  in  removing  a  kidney  by  this  method  as  in 
that  through  the  linea  semilunaris,  of  which  the  chief  only  need  be 
recapitulated  here — viz. : 


*  Tims  it  lias  hapiiened  to  Prof.  Czerny,  whose  experience  in  nephrectomy  is  almost 
unrivalled,  to  be  driven  to  tie  the  abdominal  aorta.  The  profuse  haemorrhage  met 
with  in  removing  a  large  growth  of  the  left  kidney  could  only  be  stopped  by  pressure 
on  the  abdominal  aorta.  This  vessel  was  accordingly  lied.  Death  took  place  ten  hours 
later.  It  was  found  that  the  renal  artery  had  been  torn  through  at  its  entrance  into 
the  tumor.  The  ligature  on  the  aorta  had  been  so  placed  that,  while  the  blood-siipply 
through  the  left  was  cut  off,  the  right  vessel  was  pervious. 


638  OPERATIONS  ON  THE  ABDOMEN. 

1.  Keeping  the  intestines  well  over  to  the  opposite  side  by  carefully 
aj^plied  sponges. 

2.  By  the  same  means  keeping  the  general  peritoneal  cavity  shut 
off  as  much  as  j^ossible  ;  as  pointed  out  already,  this  method  has  the 
grave  objection  of  more  readily  causing  infection  of  the  peritoneum. 

3.  Avoiding  all  large  vessels  which  are  met  with  over  the  kidney, 
and  securing  these  carefully  with  chromic-gut  or  fine  carbolized-silk 
ligatures  before  dividing  them. 

4.  Securing  as  full  access  as  possible  to  the  kidney  pedicle. 

5.  Dealing  as  gently  as  possible  with  the  kidney  when  distended 
with  fluid,  and  still  more  when  it  is  the  seat  of  a  soft  vascular  growth. 

6.  Separating  adhesions,  especially  any  situated  posteriorly,  with 
the  utmost  carefulness. 

7.  Avoiding  all  tension  on  the  pedicle. 

8.  Scrupulously  cleansing  the  site  of  the  wound. 

9.  If  fluids  or  portions  of  the  growth  have  escaped  into  the  general 
peritoneal  cavity,  ensuring  cleansing  of  this  with  sponges,  or,  perhaps 
better,  by  irrigation  with  a  warm  2  per  cent,  solution  of  boracic  acid. 

10.  Taking  care  that  the  cut  edges  of  the  peritoneum  over  the 
kidney  are  in  exact  apposition,  either  by  natural  adaptation  or  by 
the  aid  of  catgut  sutures. 

11.  Providing  sufficient  drainage  (p.  637)  if  the  operation  has  been 
a  difficult  one  and  the  parts  much  disturbed,  and,  always,  if  septic 
fluids  have  escaped  into  the  peritoneal  cavity. 

12.  Conducting  the  different  steps  of  the  operation,  especially  the 
earlier  ones,  with  as  much  expedition  as  possible,  and,  in  addition, 
providing  against  shock  by  taking  those  precautions  recommended 
for  this  purpose  in  any  grave  operation,  as  at  p.  630. 

C.  Neplirectomy  througli  the  Abdominal  Wall,  but 
without  opening  the  Peritoneum.— Having  made  use  of  this 
method  in  one  case  five  years  ago,  and  being  much  struck  by  the 
room  afforded,  I  may  make  brief  mention  of  it.  The  patient  was  a 
woman,  aged  fifty-four,  the  subject  of  a  movable  kidney  on  the  right 
side,  the  kidney  being  also  the  seat  of  malignant  disease.  As  the 
abdominal  walls  were  thin,  and  as  the  kidney  could  easily  be  made 
to  project  in  the  anterior  part  of  the  right  lumbar  region,  I  made  a 
longitudinal  incision  from  the  anterior  superior  spine  up  to  the  eighth 
rib.  The  different  layers  were  cut  through,  very  little  haemorrhage 
being  met  with ;  when  the  peritoneum  was  reached  this  was  then 
stripped  up  out  of  the  iliac  fossa,  upwards  and  inwards,  then  upwards, 
off  the  anterior  surface  of  the  kidney  until  its  vessels  came  in  view. 
No  difficulty  was  experienced  in  dealing  with  the  pedicle — first  the 
ureter,  and  then  the  vessels.  The  vena  cava  was  seen  for  about  1^ 
inch  receiving  pulsation  from  the  aorta.    The  patient  never  rallied 


NEPHRECTOMY.  639 

thbroiighly  from  the  operation,*  and  sank  about  twenty-four  hours 
after.  Post  mortem  the  ligatures  were  found  firmly  tied  ;  one  of 
those  on  the  renal  vein  had  slightly  puckered  in  the  inner  surface  of 
the  vena  cava.  A  clot  the  size  of  the  little  finger  constituted  all  the 
bleeding  that  had  taken  place.  The  kidney  was,  save  for  one  small 
patch  at  the  lower  part,  entirely  converted  into  encephaloid  carci- 
noma. Two  or  three  of  the  aortic  glands  were  enlarged ;  there  were 
no  other  secondary  deposits. 

Choice  between  Lumbar  and  Abdominal  Nephrectomy. — 
While  it  is  certain  that  all  kidneys  of  small  or  moderately  enlarged 
size  can  be  easily  removed  by  a  lumbar  incision  sufficiently  enlarged 
(p.  630),  time  alone  will  show  whether  I  am  right  in  my  belief  that 
large  kidneys  can  be  best  attacked  by  surgeons  through  an  extra- 
peritoneal abdominal  incision  {vide  supra),  or  by  the  method  of 
Konig's  (p.  631).  And  this  leads  up  to  the  question  of  chief  impor- 
tance :  How  far  is  the  danger  really  increased  by  going  through  the 
peritoneum  to  get  at  the  kidney  ?  I  am  strongly  of  opinion  that,  in 
spite  of  all  the  recent  improvements  in  abdominal  surgery  and  their 
success  in  preventing  peritomt'is,  interference  with  the  peritoneum, 
save  in  the  shortest  and  simplest  instances,  remains,  on  the  score  of 
shock,  as  grave  a  thing  as  ever  it  was.  I  am  quite  aAvare  that,  in  the 
hands  of  a  few  operators,  such  as  Sir  S.  Wells,  Mr.  K.  Thornton,  and 
Mr.  Tait,  removal  of  kidneys,  even  in  difiicult  cases,  through  an 
abdominal  wound  involving  the  peritoneum  has  given  excellent 
results — results  perhaps  as  good  as,  or  better  than,  those  b}'  the 
lumbar  method.  But  while  allowing  this,  it  cannot,  I  think,  be  lost 
sight  of  that  the  kidney  is  an  extra-peritoneal  organ,  not  one,  like  the 
uterus  and  ovary,  within  the  peritoneal  cavity.  It  will  assuredly 
never  be  brought  about  that  removal  of  the  kidney  will  pass,  like 
oophorectomy  and  removal  of  the  uterus  or  its  appendages,  into  the 
hands  of  a  few  operators  especially  skilled  in  abdominal  surgery. 
This  being  so,  and  the  organ  in  question  being  one  behind  and  out- 
side the  peritoneum,  while  each  man  will  decide  for  himself  according 
to  his  special  experience  and  line  of  work,  the  majority  of  surgeons 
will,  I  think,  prefer  to  make  their  attacks  from  behind. 

Lumbar  Nephrectomy — Advantages  : 

1.  The  peritoneum,  save  in  case  of  exceptional  difficulty,  is  not 
opened  or  contaminated.. 

2.  Efficient  drainage  is  easily  provided, 

3.  The  structures  interfered  with  are  much  less  important. 


*  I  think  that  the  thinness  of  the  abdominal  walls  prolonged  the  operation,  owing 
to  rav  anxiety  not  to  wonnd  the  peritoneum.  As  has  been  said  above,  the  haemor- 
rhage was  very  slight,  and  I  was  careful  not  to  pull  upon  the  pedicle. 


640  OPERATIONS    ON    THE    ABDOMEN. 

4.  As  pointed  out  by  Mr.  Greig  Smith,  "  in  the  case  of  its  being 
unwise,  as  in  abscess,  or  in  tumor  infecting  the  surrounding  tissues, 
to  proceed  to  removal,  it  is  less  serious  to  the  patient." 

5.  If  the  kidney  is  firmly  matted  down,  as  in  the  condition  given 
at  p.  630,  such  dense  posterior  adhesions  are  most  readily  dealt  with 
by  the  lumbar  method. 

6.  The  lumbar  incision,  if  converted  into  a  T-shaped  one,  or  pro- 
longed forward  by  Konig's  method,  will  give  sufficient  room  for 
meeting  most  of  the  conditions  which  call  for  nephrectomy.  Thus 
modified,  it  will  suffice  for  new  growths  in  their  early  stages.  If  these 
are  operated  on  later,  one  of  the  abdominal  methods  will  have  to  be 
made  use  of. 

Lumbar  Nephrectomy — Disadvantages  : 

1.  It  is  usually  thought  that  too  little  room  is  given  by  this  method 
for  the  removal  of  large  kidneys.  It  has  already  been  shown  (p.  631) 
how  extensively  this  incision  can  be  enlarged.  It  is  doubtful,  there- 
fore, if  the  above  objection  holds  good  for  any  cases,  even  those  of 
unusually  long-chested  patients,  or  those  with  spinal  deformity. 

2.  In  a  fat  subject  the  organ  may  be  difficult  to  reach,  even  when 
well  pushed  up  from  the  front. 

3.  The  pedicle  is  less  easily  reached,*  and  thus,  in  cases  of  diffi- 
culty, bleeding  at  a  very  important  stage  of  the  operation  is  less 
easily  dealt  with. 

4.  If  the  kidney  be  very  adherent,  important  structures — e.g.,  the 
peritoneum  (p.  633)  and  colon — may  be  opened  into,  unless  great 
care  is  taken. 

5.  The  condition  of  the  opposite  kidney  cannot  be  examined  into.f 
Nephrectomy  by  Abdominal  Incisions  in  the  Line  a  Alba,  or  at 

THE  Edge  of  the  Rectus,  the  Peritoneal  Cavity  being  opened — 
Advantages  : 

1.  Additional  room  in  case  of  large  kidneys. 

2.  More  easy  access  to  the  pedicle. 

3.  The  possibility  of  examining  the  condition  of  the  other  kidney. 
It  has  already  been  pointed  out  (p.  636)  that  this  advantage  is 
probably  overrated. 

Mr.  Greig  Smith;|:  thus  states  the  question  with  regard  to  the 
operation  in  the  linea  semilunaris:  "  Langenbeck's  operation  is,  in 
its  way,  a  perfect  surgical  procedure,  securing  its  aims  by  a  minimum 
of  injury  to  surrounding  tissues.  In  the  linea  semilunaris,  the  ad- 
vantages of  avoiding  large  muscular  masses  are  secured ;    and,  by 

*  This  objection  and  the  next  can  be  met  by  very  freely  enlarging  the  woiuid. 
t  Possible  fallacies  here  have  been  pointed  out,  p.  636. 
X  Abdom.  Surg.,  p.  513. 


NEPHRECTOMY.  641 

tearing  through  the  peritoneum  in  front  of  the  colon,  the  vitalit.y  of 
the  bowel  is  not  endangered.  It  gives  plenty  of  room  for  removal  of 
the  kidney.  Lastly,  it  secures  the  all-important  advantage  of  giving 
information  as  to  the  condition  of  the  alternate  kidney." 

Nephrectomy  by  Abdominal  Incisions  through  the  Peri- 
toneum— Disadvantages  : 

1.  The  peritoneal  cavity  is  opened. 

2.  The  peritoneal  cavity  may  he  seriously  contaminated  if  a 
kidney  containing  septic  matter,  or  one  largely  converted  into  soft 
growth,  is  ruptured  during  the  needful  manipulations: 

3.  The  intestines  may  be  difficult  to  deal  with,  and  may,  by 
crowding  into  the  field  of  operation  and  the  incision  in  the  abdominal 
wall,  prove  most  embarrassing. 

4.  The  vitality  of  the  colon  may,  by  interference  with  its  blood- 
supply,  be  endangered. 

5.  It  is  more  difficult,  by  this  method,  to  deal  with  any  dense  adhe- 
sions which  may  exist  behind  the  kidney, 

6.  Efficient  drainage  is  less  easily  provided  in  cases  of  any  contami- 
nation of  the  peritoneal  cavity,  or  of  oozing  after  the  kidney  is  got 
out. 

7.  The  after-complication  of  a  ventral  hernia  is  much  more  probable 
by  this  method,  though  it  must  be  allowed  that  the  free  lumbar  incision 
already  alluded  to  may  be  followed  by  the  same  objection. 

Causes  of  Death  after  Nephrectomy. 

1.  Shock. — This  may  be  induced  by  ha3morrhage,  much  traction  on 
the  pedicle,  and  thus,  probably,  interference  with  the  solar  plexus, 
injury  to  the  colon,  or,  where  the  peritoneal  cavity  is  opened,  by  much 
disturbance  of  its  contents. 

2.  Hannorrhage. — This  is  especially  to  be  dreaded  where  the  pedicle 
is  deep  and  difficult  to  command;  Avhere  there  are  aberrant  renal  ves- 
sels; where  these  vessels  are  enlarged  and  perhaps  softened;  where, 
owing  to  too  much  tension  on  the  pedicle,  a  vessel  retracts  from  within 
its  loop  of  ligature ;  where  the  kidney  capsule  and  tissue  are  broken 
into.  In  the  intra-peritoneal  method  there  is  the  additional  danger 
of  enlarged  veins  within  the  meso-colon. 

Secondary  hajmorrhage  has  been  alluded  to  above,  p.  634. 

8.  Uraemia  and  Anuria. — These  are  only  likely  to  occur  when  it  has 
been  impossible  to  form  a  correct  estimate  of  the  condition  of  the 
opposite  kidney,  or  where,  to  give  a  patient  a  chance,  the  surgeon 
operates  in  what  he  knows  to  be  a  doubtful  case.  Where  there  is 
reason  to  believe  that  the  suppression  of  urine  maj^  be  due  to  a  calculus 
in  the  opposite  kidney,  this  should  at  once  be  cut  down  upon  in  the 
hope  of  finding  a  calculus  that  can  be  removed.  A  brilliant  example 
of  what  nephrolithotomy  may  do  in  such  peril  setting  in  at  a  later 

41 


642  OPERATIONS  ON  THE  ABDOMEN. 

date  is  given  by  a  ease  of  Mr.  Lucas's,*  in  which,  four  months  after  a 
successful  removal  of  one  kidney,  a  calculus  was  successfully  removed 
from  the  remaining  one  on  the  onset  of  total  suppression. 

4.  Peritonitis. — This  may  be  simple  {i.e.,  traumatic)  or  septic.  While 
it  is  certainly  more  likely  to  follow  the  intra-peritoneal  operation,  it 
may  occur  after  that  through  the  loin,  especially  when  miich  difficulty 
is  met  with  here,  owing  to  numerous  adhesions,  or  to  working  in  a 
wound  of  insufficient  size.f 

5.  Septic  Trouble  —  Cellulitis  —  Erysipelas — Pyaemia. — These  are 
especially  likely  when  the  kidney  contains  septic  matter,  when  the 
soft  parts  are  much  bruised,  or  when  many  fingers  enter  the  wound. 

Other,  rarer,  causes  of  death  are — 

6.  Pulmonary  embolism. 

7.  Empyema. — This  may  be  brought  about  by  an  extension  of  septic 
cellulitis,  or  by  removing  during  the  operation  a  portion  of  rib  in  order 
to  get  more  room — a  step  the  danger  of  which  cannot  be  too  strongly 
enforced,  p.  614.  An  anatomical  predisposition  favoring  the  passage 
of  inflammation  from  the  kidney  to  the  pleura  has  been  pointed  out 
by  Dr.  Lange,  of  New  York.  This  authority  on  renal  surgery  found, 
in  one  subject,  in  the  diaphragm  an  enormous  gap,  the  muscle  fibres 
being  absent  from  the  ligamentum  arcuatum  internum  as  far  as  the 
outermost  part  of  the  eleventh  rib.  Between  these  two  points  the 
fibres  of  the  diaphragm  communicated  in  a  high  arch,  bounding  an 
area  in  which  the  fatty  tissue  about  the  kidney  was  in  direct  contact 
with  the  pleura, 

NEPHRORRAPHY. 
Indications. — Where  the  surgeon  is  able  to  satisfy  himself  that  a 
persevering  trial  of  a  well-fitting  belt  has  failed  ;  that  the  pain,  whether 
constant  or  paroxysmal,  is  honufide ;%  and  that  it  really  cripples  and 
spoils  the  patient's  life.  Constipation  and  dyspepsia,  will  of  course 
have  been  treated,  tight  lacing  given  up,  and  a  trial  of  massage  com- 
bined with  the  use  of  a  belt. 

Operations  for  Movable  Kidney.— These  are : 

A.  Nephrorraphy. 

B.  Nephrectomy. 

It  is  the  first  of  these  that  will  be  considered  here.     Nephrectomy 

*  Brit.  Med.  Journ.,  March  8,  1884. 

f  That  injury  to  the  peritoneum  is  not  always  fatal  here  is  shown  by  a  case  men- 
tioned (without  reference)  by  Mr.  Morris  {loc.  supra  cit..  p.  535),  in  whicii  the  pus  of 
a  scrofulous  pyelitis  had  contaminated  the  inner  surface  of  the  peritoneum.  The  patient 
here  rapidly  recovered,  the  operation,  which  lasted  two  liours  and  a  half,  having  been 
throughout  all  but  bloodless. 

X  As  when  it  is  accompanied  by  undoubted  vomiting.  Another  condition  of  movable 
kidney  which  calls  for  operation  is  when,  in  stooping,  the  viscus  comes  down  so  far  as 
to  be  jammed  between  the  ribs  and  the  crista  ilii. 


NEPHRORRAPHY.  643 

for  movable  kidney  has  been  alluded  to  at  p.  629,  and  will  be  briefly 
considered  at  p.  645. 

A.  Operation  of  Nephrorraphy.— The  kidney  is  first  exposed 
by  the  incision  *  and  the  steps  already  fully  given  (p,  614).  The 
lumbar  fascia  being  opened,  the  wound  is  widely  dilated  by  the  use 
of  retractors,  which  gather  up  the  whole  thickness  of  the  wound  down 
to  the  renal  capsule,  and  by  an  assistant  pulling  up  the  ribs  if  need 
be.  During  the  rest  of  the  operation  another  assistant  with  steady 
pressure  on  the  right  spot  forces  the  kidney  into  the  wound  and  keeps 
it  there. 

The  surgeon  now  examines  the  kidney,  as  to  whether  it  is  sound, 
enlarged,  etc.  If  the  viscus  be  quite  healthy,  the  surgeon  next,  in  the 
words  of  Mr.  Greig  Smith,  seeks  ''  to  diagnose  the  exact  nature  of  the 
conditions  associated  wdth  the  mobility.  If  it  is  clear  that  the  fatty 
tunic  is  closely  adherent  to  the  fibrous  capsule,  the  former  need  not 
be  opened.  But  if  the  kidne}-  has  space  for  movement  inside  its  fatty 
capsule,  then  this  ought  to  be  freely  opened,  and  the  finger,  inserted 
through  this  opening,  moved  freely  over  the  renal  surface,  so  as  to 
excite  plastic  inflammation." f 

Several  questions  now  arise  as  to  the  sutures.  (1)  What  is  the  best 
material?  (2)  What  tissues  are  to  be  taken  up ?  (3)  Are  they  to  be 
dropped  in? — (1)  The  sutures  should  be  of  both  carbolized  silk  and 
chromic  gut  if  they  are  going  to  be  dropped  in ;  of  carbolized  silk  only 
if  they  are  left  for  subsequent  removal.  (2)  With  regard  to  the  tissues 
taken  up,  the  sutures  should  certainly  include  kidney  tissue  itself  In 
other  words,  passing  them,  however  numerously,  into  the  peri-renal 
fat  or  kidney  capsule  will  not  be  sufficient.  This  was  well  seen  in  the 
case  of  nephrorraphy  mentioned  at  p.  644,  in  which,  after  numerous 
sutures  had  been  thus  i)laced,  the  kidney  still  dropped  away  out  of 
sight  as  before. 

The  tliird  question,  whether  the  sutures  are  to  be  dropped  in  or  not, 
is  still  an  open  one.  Most  surgeons,  I  believe,  do  so,  and  this  was  the 
method  I  adopted  in  two  cases  of  nephrorraphy.  The  kidney  being 
thoroughly  exposed,  pushed  well  up,  and  its  structure,  the  amount  of 
surrounding  fat,  and  the  looseness  of  capsule  having  been  examined, 
the  surgeon  passes  from  four  to  six  sutures — some  of  carbolized  silk, 
some  of  gut — through  adjacent  parts  of  the  kidney  itself  and  the 
deeper  of  the  soft  parts.  The  material  used  is  of  medium  size,  so  as 
not  to  cut  out  too  readily,  and  the  needles  are  curved  and  used  with 
a  holder.    The  sutures  should  be  inserted  one  or  two  at  the  lower  end, 

*  In  a  fat  patient  a  J-s'iaped  incision  will  be  needed. 

t  If  this  be  carefully  done  with  an  aseptic  finger,  there  is  no  fear  of  exciting  dan- 
gerous cellulitis.  With  this  operation  carried  out  witli  strict  precautions,  there  is  fear 
of  too  little  rather  than  of  too  luiicli  inflammation. 


644  OPERATIONS    ON    THE   ABDOMEN. 

two  or  three  at  the  outer  and  one  or  two  at  the  inner  border.  They 
should  dip  well  into  the  kidney  tissue  on  the  one  hand,  and  pass 
through  the  lumbar  fascia  and  muscles  on  the  other.  Wlien  sufficient 
are  inserted  and  knotted  so  that  the  kidne^y  no  longer  falls  away  when 
the  su]:»porting  hand  of  an  assistant  is  removed,  a  little  iodoform  is 
dusted  in,  the  sutures  are  cut  short,  and  the  wound  over  them  closed 
with  silk  and  wire  sutures. 

Very  little  bleeding  follows  the  simple  punctures  of  tlie  kidney- 
substance  implied  in  the  above  method. 

The  objection  to  this  plan  is  that  if  only  chromic-gut  sutures  are 
made  use  of,  they  may  soften  and  come  away  too  soon.*  If  silk  are  used, 
even  when  care  has-  been  taken  with  the  preparation,  they  may  come 
away  with  vexatious  repetitions  through  a  long  persistent  sinus  (p.  404). 

Another  method  is  one  used  by  Mr.  ]Morris,t  and  consists  in  passing 
sutures  of  silk  and  chromic  gut  through  the  entire  thickness  of  one  lip 
of  the  wound,  then  through  the  capsule  and  cortex  of  the  kidney,  and 
finally  through  the  other  lip  of  the  wound.  When  these  sutures  are 
tied,  the  wound  is  closed  and  the  kidney  fixed  at  the  same  time. 
Some  buried  sutures  passing  between  the  kidney  and  the  deep  part 
of  the  incision,  might  be  made  use  of  as  well.  In  one  of  Mr.  Morris's 
cases  a  single  stout  catgut  suture  passed  as- above  seems  to  have  been 
successful  in.  fixing  the  kidney.  In  the  other  case,  where  silk  and 
catgut  sutures  were  thus  passed,  the  former  was  not  removed  till  the 
thirteenth  day. 

Two  cases-  of  nephrorraphy  have  been  lately  under  my  care.  In 
the  first  the  kidney  proved  to  be  not  only  movable  but  the  seat  of 
pyelitis  as  welL  The  woman,  aged  forty- four,  was  a  patient  of  Dr. 
F.  Taylor's  ;  other  treatment,  including  a  well-fitting  belt,  having 
failed  to  give  relief,.  I  was  asked  to  perform  nephrorraphy.  The  loin 
being  a  thin  one,  and  the  kidney  easily  brought  up  to  the  surface,  the 
operation  was  very  easy..  I  began  by  putting  in  eight  or  ten  gut 
sutures  between  the  peri-renal  tissues  and  the  edges  of  the  wound. 
These  had  no  effect  whatever,  as  when  my  dresser,  Mr.  A.  E.  Poolman, 
removed  the  very  efficient  support  which  he  was  applying  through 
the  abdominal  walls,  the  kidney  receded  completely  out  of  sight. 
Three  carbolized  silk  sutures  passed  between  the  kidney  itself  (the 
needle  being  dipped  well  into  its  substance)  and  the  edges  of  the  in- 
cision, and  cut  short,  kept  the  kidney,  without  any  other  support, 
quite  up  in  the  wound  ;  in  fact,  the  patient  being  thin,  the  organ  now 
lay  almost  subcutaneous.    The  wound  was  so  completely  closed  by 

*  Dr.  Newman  {Glasg.  Med.  Journ.,  1883)  has  observed,  as  might  be  expected,  that 
the  part  of  tlie  catgut  sutures  whicli  lies  in  the  vascular  kidney-tissue  itself  softens 
witli  especial  quickness. 

t  Annals  of  Surgery,  April,  1887. 


ACUTE    INTESTINAL    OBSTRUCTION.  645 

the  viscus  that  no  drainage-tube  could  be  inserted.  Primary  union 
took  place  throughout,  and  the  wound  was  healed  in  ten  days.  About 
two  months  later,  the  pain  being  re-established,  further  examination 
proved  that  the  urine,  which  had  before  been  found  normal,  now 
contained  pus.  Three  months  after  the  nephrorraphy  I  explored  the 
wound.  This  was  rendered  a  little  difficult  by  the  incision  passing 
through  scar  tissue.  The  silk  sutures  fixing  the  kidney  were  found 
in  situ.  The  kidney  itself  now  showed  two  cystic  expansions,  both 
small — one  about  the  size  of  a  hen's  egg,  the  other  that  of  a  walnut — 
one  at  the  upper  and  one  at  its  lower  extremity.  Fine  trocar  punct- 
ures removed  pus.  After  consultation  with  my  colleague,  Mr.  Howse, 
I  removed  the  kidney.  Not  being  much  enlarged  it  came  out  easily 
through  the  ordinary  lumbar  incision,  and  the  patient  made  a  good 
recovery.* 

B.  Nephrectomy  for  Movable  Kidney. — This  operation  will 
be  very  rarely  required.  It  should  be  reserved  for  cases  where  (i) 
the  kidney  is  not  onl}-  movable,  but  diseased,  as  at  j^p.  639,  644.  (ii) 
Where  nephrorraphv  has  failed,  (iii)  Where  a  misplaced,  movable 
kidney  cannot  be  jjushed  back  into  the  loin.f 


CHAPTER  V. 

OPERATIONS  ON  THE  INTESTINES. 

ACUTEt  INTESTINAL  OBSTRUCTION.— ENTERQTOMY. 
—FORMATION  OF  ARTIFICIAL  ANUS  IN  INTESTI- 
NAL OBSTRUCTION.— SUPPURATIVE  PERITONITIS. 
—CLOSURE  OF  ARTIFICIAL  ANUS  AND  RESECTION 
OF  INTESTINE.-COLECTOMY. 

ACUTE  INTESTINAL  OBSTRUCTION. 

The  following  practical,  though  very  brief,  remarks  on  the  chief 
varieties  may  be  helpful  at  the  time  of  operation  : 

*  Tlioiiffh  the  kidney  had  been  carefully  inspected  at  the  previous  operation  by  Dr. 
Taylor  and  myself,  though  I  had  had  opportunities  of  handling  it,  and  though  the 
needle-punctures  gave  vent  only  to  blood,  I  think  the  suppuration  must  have  been 
present  at  the  time  of  the  nephrorraphy.  Thig  case  and  that  recorded  at  p.  6S3  show 
that  movable  kidneys  do  sometimes  have  a  basis  of  organic  disease. 

I  would  alhide  to  another  case  of  nephrorraphy  to-euiphasize  the  remarks  made  in 
the  foot-note  at  p.  404.  Here,  in  inserting  six  sutures  of  carbolized  silk  between  the 
lower  extremity  and  borders  of  the  kidney  and  the  edges  of  the  cut  lumbar  fascia,  I 
made  use  of  tJie  closely  plaited  silk  known  as  Turner's.  This  can  so  resist  all  cell 
changes,  etc  ,  that  for  eleven  months  the  sinuses  persisted,  discharging  these  silk  sutures 
absolutely  unchanged.  I  finally  had  to  open  up  the  sinus  and  remove  the  la-st  stitch. 
It  was  absolutely  unaltered.  t  Morris,  Surg.  Dis.  of  the  Ktdney,  p.  42. 

X  Chj-onic  intestinal  obstruction  has  been  alluded  to  under  the  head  of  Colotoiny,  p,593. 


646  OPERATIONS  ON  THE  ABDOMEN. 

A.  Strangulation  by  Bands  and  through  Apertures.* 

1.  Adventitious  peritoneal  bands.  Perhaps  there  has  been  a  history 
of  peritonitis,  starting  possibly  from  the  ca?cum,  the  uterus,  and 
appendages,  or  a  mesenteric  gland.  These  bands  are  usually  attached 
by  one  end  to  the  mesentery. 

2.  Omental  bands.  Here  some  part  of  the  lower  end  of  the  omen- 
tum has  become  adherent  to  the  brim  of  the  pelvis,  a  hernial  sac,  the 
uterine  appendages,  or  the  caecum. 

3.  MeckeFs  diverticulum..  This  is  usually  met  with  in  young  sub- 
jects. Tubular  or  cord-like,  it  will  be  found  attached  at  one  end  to 
the  ileum,  within  3  feet  of  the  cajcum,  at  the  other  near  the  umbilicus, 
or  to  the  mesentery  or  intestine.  Under  this  arch  small  intestine  is 
very  liable  to  slip.  In  other  cases  one  end  is  free,  and  ensnares  or 
knots  up  a  loop  of  intestine. 

4.  Some  normal  structure  abnormally  attached.  Such  are  a  Fallo- 
pian tube  or  the  vermiform  appendix. 

5.  Some  aperture  or  slit.  This  may  be  congenital  or  traumatic,  and 
situated  in  the  omentum,  mesentery,  etc. 

In  all  the  above,  the  lower  part  of  the  ileum  is- the  portion  usually 
strangulated. 

B.  Vohndus. — The  intestine  here  is  usually  either  twisted  on  its 
mesenteric  axis,  or  bent  at  an  angle.  The  former  is  the  more  acute 
condition,  owing  to  the  strangulation  of  vessels.  It  is  much  most 
common  in  the  sigmoid  flexure,  when  this  has  a  long  meso-colon, 
especially  in  adults  who  have  been  subject  to  constipation  (Treves). 

The  distension  may  be  enormous,  this  part  of  the  intestine  appear- 
ing to  occupy  all  the  abdominal  cavity.  Ulceration  leading  to  fatal 
peritonitis  may  set  in  either  in  this  intestine,  or  in  the  colon  or  ctecum 
(p.  604). 

C.  Strictures. — These  have  been  considered,  with  chronic  obstruction, 
under  the  head  of  colotomy  (p.  593). 

D.  Foreign  Bodies  {e.g..  Gallstones)  becoming  Impacted.— The  patients 
here  are  usually  over  forty-five :  often  stout  women  of  sedentary 
habits,  with  history  of  past  colic,  etc.  The  stone  is  usually  a  large 
one  which  has  ulcerated  into  the  duodenum.  The  urgency  of  the 
symptoms  will  vary,  of  course,  with  the  size  of  the  stone,t  the  com- 

*  Mr.  Treves  {Intest.  Obstruct.,  p.  13 ;  Diet,  of  Surg.,  vol.  ii.  p.  802)  groups  these 
together  from  llie  sioiihirity  of  their  obstruction  and  their  close  resemblance  to  strangu- 
lated hernia.     The  above  classification  is  borrowed  from  Mr.  Treves. 

f  Sometimes  no  such  history  is  obtainable.  Tims,  in  a  very  interesting  case  of  Mr. 
Bryant's  {Clin.  Soc.  Trans.,  vol.  xii.  p.  106),  in  which  he  removed  a  gall-stone  from 
the  ileum  which  had  caused  complete  obstruction  for  three  days,  the  patient  is  stated 
to  have  been  perfectly  healthy  up  to  the  time  of  the  attack,  save  for  occasional  indi- 
gestion. At  the  post-mortem  examination  an  old  communication  was  found  between 
the  gall-bladder  and  the  duodenum. 


INTUSSUSCEPTIOX.  647 

pleteness  of  the  impaction,  and  the  site.  This  is  usually  in  the  lower 
ileum. 

E.  Intussusception. — From  its  frequency,  especially  in  young  life, 
its  fatalit}'  in  infants,  the  fact  that  its  treatment  is  more  satisfactory 
because  its  diagnosis  is  easier  than  other  forms  of  obstruction,  this 
form  of  intestinal  obstruction  deserves  careful  notice.  Of  the  varieties 
— the  enteric,  the  colic,  the  ileo  colic,  and  the  ileo-caecal — the  fre- 
quency of  the  last  is  well  known.  It  is  to  this  variety,  especially  in 
children,  that  the  following  remarks  mainly  apply. 

The  frequency  with  which  intussusception  is  still  left  undiagnosed 
must  receive  mention,  a  fact  which  appears  to  be  due  to  a  failure  to 
examine  the  rectum,  or  to  a  misinterpretation  of  what  is  found  there 
in  acute  cases  (an  intussusception  being  called  a  prolapsus),  and,  in 
less  acute  cases,  to  their  sometimes  presenting  very  few  symptoms  at 
all. 

With  regard  to  treatment,  it  cannot  be  too  strongly  insisted  upon 
that,  in  this  form  of  obstruction,  there  is  no  excuse  for  delaying 
active  treatment.  If  intussusception  is  suspected,  the  trial  of  bella- 
donna or  opium,  warmth  aided  by  friction,  should  be  a  brief  one ; 
and  if  a  tumor  is  to  be  felt,  especially  if  per  rectum  as  well  as  through 
the  abdomen,  it  should  be  briefer  still.  No  delay  should  be  lost  in 
trying  inflation  or  injection.  I  prefer  to  begin  with  the  former.  A  little 
ether  being  given,  the  lower  limbs  being  somewhat  raised,  the  nozzle 
of  a  Lund's  inflator,  or  a  full  sized  catheter,  or  a  rectal  tube,  attached 
by  tubing  to  a  bellows  and  well  coated  with  vaseline,  is  carefully 
passed  into  the  bowel.  The  nates  being  securely  pressed  round  the 
tube,  air  is  steadily  pumped  into  the  colon,  while  the  surgeon  keeps 
one  hand  on  the  abdomen,  not  only  to  prevent  over-distension,  but 
also  to  watch  for  any  receding  of  the  tumor  towards  the  csecal  region. 

With  regard  to  the  force  used.  Dr.  Goodhart  (loc.  supra  ciL,  p.  125) 
remarks :  "  Replacement  of  the  bowel  can  usually  only  be  effected  by 
considerable  distension  of  the  whole  colon,  and  distension  of  the 
colon  sometimes  requires  a  good  deal  of  rather  forcible  pumping  to 
complete  it."  This  is  especially  the  case  with  regard  to  the  last  few 
ounces  of  air  sent  in.  Probably  the  advice  of  Dr.  Taylor*  on  this 
point  will  minimize  the  risk  of  rupture  of  the  bowel.  "  The  risk  can 
be  reduced  to  a  minimum  by  injecting,  carefully  and  slowly,  succes- 

*  Clin.  Soc.  Trans ,  vol.  xvi.  p.  71.  Dr.  Taylor  thinks  that  two  kinds  of  cases  are 
unsuiled  for  inflation  :  One,  in  which  the  intussusception  actually  projects  from  the 
anus,  as  this  form  shows  enormous  forcing  power  on  the  part  of  the  intestine,  while, 
after  replacement  by  the  fingers,  the  amount  of  air  that  can  be  brought  to  bear  is 
necessarily  small.  Dr.  Taylor's  other  group  unsuited  for  inflation  is  where  no  tumor 
can  be  felt  and  the  diagnosis  depends  solely  on  symptoms.  lie  points  out  that  here 
it  is  impossible  to  judge  of  the  etiects  of  inflation. 


648  OPERATIONS  ON  THE  ABDOMEN. 

sive  small  quantities,  and  by  gently  kneading  the  abdomen  so  as  to 
facilitate  the  passage  of  air  upwards,  and  thus  prevent  the  sudden 
over-distension  of  short  lengths  of  the  colon."* 

Inflation  failing,  if  the  condition  of  the  patient  admits  of  it,  more 
powerful  means  may  be  made  use  of  by  connecting  the  rectal  tube 
wilh  an  improvised  water-cistern,  placed  high  above  the  bed,  a  more 
equable  and  forcible  distension  being  thus  obtained.f 

These  methods  failing,  while  the  child  is  still  under  an  anaesthetic, 
preparations  should  be  made  for  operation.  Before  describing  this,  it 
may  be  useful  to  point  out,  as  tfir  as  this  is  possible,  in  what  cases 
this  is  likely  to  be  called  for  and  how  often  it  is  likely  to  be  suc- 
cessful. The  following  will  help  towards  an  answer  to  the  above 
questions : 

a  The  duration  of  the  case.  In  the  majority  of  cases,  especially  in 
children,  the  tendency  of  the  condition  is  to  strangulation,  and  not 
incarceration,  and  while  the  rapidity  of  the  strangulation  varies  a 
good  deal,  the  chances  of  inflation  or  injection  are  small,  unless  in 
recent  cases. 

/3  If  the  above  is  correct,  it  is  obviously  of  much  importance  to 
decide  whether  the  bowel  is  strangulated  or  incarcerated.  Mr. 
Hutchinson  (^Med.  Chir.  Trans.,  vol.  Ivii.  p.  31)  points  out  that  the 
severity  of  the  symptoms  will  be  helpful  here— viz.,  the  urgency  of 
the  vomiting,  the  degree  of  the  constipation,  the  character  of  any 
stools  passed,!  ^tc,  any  indications  of  collapse,  and,  above  all,  as 
utterly  incompatible  with  gangrene,  advance  of  the  tumor  further  on 
in  the  large  intestine.§ 

*  Tlie  value  of  this  was  sliowii  decisively  in  the  case  of  an  infant  recently  inflated 
by  Dr.  Perry  and  myself.  Pumping  in  of  air  had  at  first  little  eflTect ;  while  it  was 
continued,  and  my  colleague  manipulated  the  parts,  first,  one  gently  snapping  sound, 
and  a  little  later  a  louder  one,  as  of  unfolding  intestine,  were  heard,  and  the  swelling 
was  found  to  have  disappeared.  Though  the  infant  passed  a  natural  motion,  the 
intussusception  recurred. 

t  Goodhart  {loc.  supra  ciL).  It  is  pointed  out  that  this  method  entails  a  greater 
risk  of  rupture  of  the  bowel,  but  that  the  end  justifies  the  means  (considering  the 
great  danger  of  these  cases),  provided  that  the  requisite  distension  cannot  be  pro- 
cnred  without. 

I  Dr.  Fagge  and  Mr.  Howse  {Med.  Chir.  Trans.,  vol.  lix.  p.  90)  point  out  that 
blood  in  the  stools  of  these  ca.ses  does  not  necessarily  mean  strangulation  and  threat- 
ening gangrene.  Thus  it  may  be  present  in  chronic  cases,  from  the  first,  as  in  Mr. 
Hutchinson's,  where  blood-stained  mucus  was  passed  for  a  month,  at  the  end  of  which 
time  Mr.  Hutchinson  was  still  able  to  reduce  the  intussusception  by  a  successful 
operation.  In  other  chronic  cases  no  blood  may  be  passed  for  a  long  time;  it  may 
then  appear  with  other  symptoms  and  rapidly  destroy  life,  though  no  gangrene  is 
present.  Lastly,  in  some  of  the  cases  in  which  the  bowel  has  sloughed  away,  no  blood 
has  been,  at  any  time,  passed. 

§  Dr.  Goodhart  (loc.  supra  cit.,  p.  122)  points  out  that  while  this  symptom  means 
that  no  sloughing  and  no  firm  adhesions  are  present,  it  cannot  be  inferred,  owing  to 


IIsTUSSUSCEPTlOX.  649 

7  The  condition  of  the  patient  as  to  collapse,  etc. 

d.  Age.  In  infants  under  a  year,  unless  reduction  is  early  tried  and 
is  quickly  successful,  the  prognosis  is  very  desperate  whether  an 
operation  is  performed  or  no.  Mr.  Hutchinson  thinks  that  this  fact 
may  he  held  to  justify  very  eaiiy  resort  to  operation. 

The  same  surgeon  thinks  that,  while,  on  the  one  hand,  the  cases 
best  suited  for  operation  are  those  which  have  persisted  for  some 
considerable  time,  and  in  which  the  intestine  is  only  incarcerated, 
on  the  other  hand,  "  cases  in  which  the  symptoms  are  very  severe,  or 
the  stage  greatly  advanced,  it  may  be  wiser  to  decline  the  operation 
and  to  trust  to  opiates." 

Operation.— The  child  being  still  under  the  influence  of  the  ether 
which  has  been  given  for  the  attempted  reduction,  the  parts  being 
cleansed  and  any  urine  drawn  off,  an  incision  is  made,  usually  in  the 
middle  line,'-'  sufficient  to  admit  of  the  easy  introduction  of  two  or 
three  fingers.  Before  opening  the  peritoneal  cavity  the  bleeding 
should  be  entirely  arrested.  The  intussuscepted  mass  is  now  found, 
and,  if  possible,  hooked  out  into  the  wound.  If  this  be  feasible, 
careful  persevering  attempts  are  made  at  reduction  by  a  continued 
action  of  gently  squeezing  the  lower  end  of  the  mass  so  as  to  push 
out  the  ensheathed  mass,  while  at  the  same  time  the  ensheathing 
layer  is  drawn  off. 

If  the  parts  are  not  sufficiently  mobile  to  allow  of  thus  bringing 
up  the  intussusception,  the  wound  must  be  enlarged  sufficiently  to 
introduce  two  fingers  of  each  hand.  The  following  remarks  of  Mr. 
Hutchinsonf  show  how  great  may  be  the  difficulties  and  the  best 
means  of  meeting  them.  Having  failed  to  hook  up  the  mass  or  to 
reduce  it  in  situ,  he  was  "  obliged  to  enlarge  the  wound  freely  above 
the  umbilicus,  and  to  allow  the  intestines,  much  distended  with  gas, 
to  escape.  It  was  only  when  the  abdomen  was  almost  empty  that  I 
could  bring  the  neck  into  view  in  the  wound,  and  then  made  repeated 
attempts  to  draw  the  bowel  out,  but  without  success.  That  there 
were  no  adhesions  was  proved  by  the  fact  that  an  inch  or  two  could 
be  easily  drawn  out,  the  impediment  was  clearly  due  to  the  ensheath- 
ing bowel  being  thrown  into  folds  by  traction,  and  thus  constituting 
a  series  of  strictures  which  gripped  its  contents.  In  this  dilemma, 
and  when  almost  in  despair  as  to  whether  I  should  accomplish  the 
reduction,  it  occurred  to  me  to  seek  the  lower  end  of  the  invaginated 
part,  and  try  to  hold  the  ensheathing  part  to  prevent  its  being  drawn 

the  oedema  and  inflammation  which  are  already  present,  that  because  the  tumor  thus 
alters  its  position,  therefore  it  can  be  reduced. 

*  Or  in  one  linea  semilunaris,  usually  tlie  left. 

t  Med.  C'hir.  Trans.,  vol  lix.  p.  100.  The  patient  in  this,  Mr.  Hutchinson's  second 
case,  was  only  six  months  old,  and  died  of  peritonitis. 


650  OPERATIONS  ON  THE  ABDOMEN. 

into  folds Tlie  attempt  to  hold  the  ensheathing  layer  straight 

at  once  revealed  the  true  mode  of  reduction,  for  by  pulling  this 
downwards  instead  of  trying  to  pull  the  involved  part  upwards,  I 
accomplished  the  rei:)lacement  with  the  greatest  ease."*  Mr.  Hutch- 
inson thinks  that,  in  future,  the  lower  ends  should  be  always  first 
caught,  and  that  reduction  by  squeezing  this  or  pulling  the  sheath 
down  rather  than  dragging  the  contained  tube  out  might  be  accom- 
plished without  In-inging  the  parts  into  view.  If  this  failed  it  would 
be  more  easy,  in  intussusception  into  the  descending  colon,  to  bring 
the  lower  part  into  the  wound  than  the  upper  one.  This  opinion  of 
Mr.  Hutchinson's  has  been  confirmed  by  the  following  cases — e.g.^  Mr. 
Howse's,  a  successful  operation  on  an  adult  {Med.  Chir.  Trans.,  vol, 
lix.  p.  88);  Mr.  H.  Marsh's  case,  also  successful  (ibid.,  p.  81),  in  an 
infant  seven  months  old  ;  and  in  another  case  of  the  same  surgeon's 
(St.  Barth.  Hosp.  Reports,  vol.  xii.  p.  98).  Here,  as  by  no  justifiable 
force  could  any  part  be  drawn  out,  the  contained  bowel  was  pushed 
or  backed  out  by  gentle  squeezing  movements  between  the  finger  and 
thumb,  these  being  shifted  gradually  upwards  along  the  gut  till  the 
caecum  appeared. 

Whichever  method  is  found  to  answer  best  must  be  persevered 
with  till  every  atom  of  the  mass  is  reduced,  this  being  often  known 
by  the  appearance  of  the  vermiform  appendix. 

Sometimes  the  success  may  be  only  partial,  the  last  inches  of  an 
intussusception  resisting  every  attempt  at  reduction.  Thus,  in  Dr. 
Fagge's  and  Mr.  Howse's  paper  (loe.  supra  cit.)  a  case  is  given  of  a 
child  aged  five  months  who  had  suffered  for  a  month  from  ileo-csecal 
intussusception.  At  the  operation  a  large  part  was  reduced  without 
difficulty,  but  the  last  4  inches  were  so  adherent  and  softened  that 
even  gentle  traction  caused  two  rents,  from  which  fgeces  escaped.  The 
remaining  intussusception  was  therefore  cut  away,  and  the  ends 
sutured.     The  child  only  survived  a  few  hours. 

In  a  child  aged  seven  months,  to  which  I  was  called  by  Dr. 
Warner,  of  Woodford,  though  symptoms  had  only  lasted  about  thirty- 
eight  hours,  I  was  unable  to  completely  reduce  an  intussusception 
which  had  reached  half-way  down  the  descending  colon.  The  lower 
end  could  only  just  be  brought  into  view;  by  a  continued  traction 
and  upward  squeezing  a  few  inches  were  reduced,  and  then  there  was 
an  absolute  block.  Further  attempts  caused  a  tear  in  the  peritoneal 
coat  at  one  spot,  and  as  the  child  was  much  collapsed,  the  symptoms, 
in  spite  of  the  verj'-  short  duration,  having  been  very  acute  from  the 

*  To  meet  the  diflBculty  of  reducing  the  small  intestines,  Mr.  Hutchinson  punctured 
them  at  two  or  three  spots  to  let  out  flatus.  Unfortunately,  faeces  escaped  from  one, 
which  required  closing. 


OPERATION    IN    ACUTE    INTESTINAL    OBSTRUCTION.  651 

first  (they  appear  to  have  been  started  by  the  father  dancing  the  child 
up  and  down),  and  having  resisted  repeated  attempts  at  infiation,  I 
felt  compelled  to  close  the  abdomen.  Death  folloAved  a  few  hours 
later. 

Every  care  should  be  taken  throughout  the  operation  to  prevent 
chilling,  both  of  the  child's  body  and  limbs,  and  especially  of  any 
intestine  w'hich  may  have  to  be  withdrawn,  p.  655.  For  these  reasons 
I  do  not  advise  the  use  of  the  spray  in  a  child,  preferring  to  irrigate 
the  wound  in  the  abdominal  wall,  and  to  adopt  the  other  precautions 
given  a  little  later,  as  to  instruments,  irrigation  of  peritoneal  cavity  if 
needful,  and  closure  of  the  wound. 

As  in  all  abdominal  sections,  this  o-peration  should  be  concluded 
as  speedily  as  ma}'  be. 

The  chief  points  in  the  after-treatment  consist  in  a  wise  use  of 
warmth,  milk  and  brandy,  and  laudanum. 

EXPLORATION  OF  ABDOMEN  IN  ACUTE  INTESTINAL 

OBSTRUCTION. 

Question  of  Operation  in  these  Cases. 

While  it  is  impossible,  owing  to  the  obscurity  of  the  diagnosis,  to 
lay  down  any  definite  rules,  I  trust  that  the  follo^^ing  remarks  may 
be  found  of  some  help  : 

1.  Difficulty  of  Diagnosis. — This  is  a  matter  of  twofold  importance, 
(a)  Is  the  case  one  of  acute  obstruction  at  all,  or  is  it  one  of  peri- 
tonitis, or  peri-typhilitis?  (/5)  If  the  symptoms  are  due  to  some 
medianical  cause  brought  about  by  acute  obstruction  in  the  form  of  a 
band,  internal  hernia,  or  volvulus,  which  of  these  is  it;  and  is  it  one 
admitting  of  remedial  interference? 

It  seems  to  me  that  this  is  one  of  those  instances  in  which  the 
advances  made  in  operative  surgery  have  outstri23ped  those  of  diag- 
nosis. From  the  necessarily  hidden  nature  of  the  lesion  this  must  be 
so,  but  as  long  as-  the  diagnosis  of  these  cases  remains  so  obscure,  so 
long  shall  we  be  uncertain  and  hesitating  in  our  treatment. 

2.  U7toi  is  the  Proportion  of  Natural  Recoveries  ivithout  Operation  in 
Cases  of  Acute  Intestinal  Obstruction  f — On  this  point  there  are  two 
quite  different  camps  of  opinion,  and  neither,  it  seems  to  me,  can 
really  point  to  any  better  success  than  the  other.  On  the  one  hand, 
Mr.  Hutchinson,  a  man  of  vast  experience  and  one  of  the  acutest 
observers  the  profession  has  ever  known,  submitted  this  proposition 
to  the  Bath*  Meeting  of  the  Association  :  "  In  the  present  state  of 
surgical  knoAvledge,  exploratory  operations  for  the  relief  of  abdominal 
obstruction,  the  cause  of  which  cannot  be  diagnosed,  are  not  warrant- 

*  Brit.  Med.  Joum.,  1878,  vol.  ii.  p.  305. 


652  OPERATIONS  ON  THE  ABDOMEN. 

able."  Mr.  nutcliinson  based  tliis  opinion  on  the  fact  that  instances 
of  spontaneous  recovery  in  acute  intestinal  obstruction  are  "  very 
numerous,  and  that  they  prove  conclusively  that  no  one  can  tell 
when  an  abdominal  obstruction  case  of  uncertain  diagnosis  is  hoiDe- 
less,  and  that  unless  it  be  practically  so,  the  dangerous  expedient  of 
opening  the  abdominal  cavity  is  not  justifiable." 

On  the  other  hand,  we  have  surgeons— e.(/.,  Mr.  Treves  and  Mr. 
Greig  Smith* — condemning  expectant  treatment,  and  strongly  urging 
an  early  resort  to  abdominal  section. 

I  am  compelled  to  say  that  Mr.  Hutchinson's  reasoning  does  not 
carry  conviction  to  my  mind.  Though  he  stated  that  he  knew  that 
cases  of  spontaneous  recovery  in  acute  obstruction  are  very  numerous, 
he  only  alluded  to  three,  and  that  briefly.  Now  two  of  these  were 
not  cases  of  acute  obstruction.  One  was  "  a  woman  of  middle  age  " 
who  "  had  suffered  from  obstruction  during  a  long  period."  Another, 
"  a  woman  aged  forty,  had  experienced  obstruction  for  twenty-five 
days."  The  third  is  extremely  briefly  mentioned,  and  nothing  is 
said  about  its  duration. 

But  while  I  difler  toto  coelo  from  Mr.  Hutchinson  as  to  the  frequency 
of  spontaneous  recovery,  while  I  agree  with  those  surgeons  who  hold 
that  such  recovery  is  quite  exceptional,  I  cannot  think  that  they  have 
proved  their  case  that  the  indication  is  clear  for  early  operation. 
Every  one  who  has  even  a  limited  acquaintance  with  surgical  litera- 
ture must  have  noticed  the  number  of  operations  that  have  been 
performed  for  acute  obstruction  in  late  years.  Yet  how  few  have 
been  successful.  And  can  any  one  doubt  that  the  published  cases 
bear  a  small  proportion  of  the  whole  number  submitted  in  late  years 
to  operation?  I  am  aware  that  the  answer  is  that  the  surgeon  is  not 
called  in  till  too  late.  Not  being  without  experience  in  this  matter,  I 
fear  that  this  answer  will  not  cover  all  the  cases.  It  is  at  least  a 
striking  fact  that  those  who  are  rightly  considered  authorities  on  this 
subject,  men  who  have  had  the  opportunities  of  urging  early  opera- 
tions, have  not  been  able  to  publish  cases  which  should  make  us  hope 
at  least  that  the  tide  is  on  the  turn.  And  this  leads  me  up  to  my 
next  point. 

3.  A  certain  Proportion  of  these  cases,  probably  a  large  one,  are  hopeless, 
if  not  from  the  first,  so  early  in  the  case  as  to  render  any  operation  futile. — 
I  say  this  not  as  holding  pessimist  views  on  this  question,  but  from  a 
deep  conviction  from  numerous  cases  that  I  have  seen,  and  several 

*  The  following  are  Mr. Greig  Smith's  words:  "To  cases  of  acute  obstruction  there 

is  practically  but  one  termination — death Certainly  95   per  cent,  of  all  such 

cases  die.  Here,  then,  the  indication  is  clear  enough — as  clear  as  the  indication  to 
tie  a  bleeding  carotid — operation." 


OPERATION    IN    ACUTE    INTESTINAL   OBSTRUCTION.  653 

that  I  have  oiDerated  upon.  I  refer  not  of  course  to  cases  of  intussus- 
ception, or  simple  bands  *  but  to  those  of  volvuli  with  severity  of 
twist,  complicated  snaring  or  knitting  up  by  bands,  and  matting  of 
coils  b_v  old  inflammation  started  in  mesenteric  glands.  To  name 
one  more  condition,  how  often  has  the  surgeon  in  operating  found 
the  obstruction,  set  free  some  imprisoned  loop,  and  then  found  all 
his  trouble  made  of  nought,  this  first  loop  being  only  lately  drawn 
under  the  constriction,  by  another  coil  which  he  finds  deep  in  the 
pelvis,  evidently  the  source  of  the  trouble,  and  for  some  time  past 
recovery  ? 

In  writing  this  I  would  not  dissuade  from  early  operations,  but  I 
cannot  agree  with  the  tendency  which  has  set  in  at  the  present  time 
to  write  and  say  that  the  onl}^  reason  these  operations  are  not  suc- 
cessful is  because  they  are  performed  too  late.  Even  if  it  is  possible 
to  operate  always  early  a  considerable  proportion  will,  unless  I  am 
mistaken,  continue  to  baffle  us. 

4.  The  comparisons  which  have  been  made  between  an  operation  in 
these  cases  of  acute  obstruction  and  those  for  hernise,  between  abdominal  sec- 
tion here  and  in  ovariotomy^  is  most  misleading  and  danger6us.  Thus, 
a  surgeon  for  whom  I  have  the  highest  respect,  Mr.  Teale,  writes 
thus  :  "  As  to  the  impunity  with  which  the  peritoneal  cavit}^  may  be 
ojiened,  I  need  hardly  remind  you  how  constantly  this  is  proved  in 
operations  for  hernia.  We  think  nothing  of  pulling  out  and  handling 
coils  of  intestine,  and  we  rarely  look  for  danger  unless  the  bowels 
have  been  damaged  by  too  long  continued  strangulation."  I  am 
afraid  the  two  cases  are  not  comparable.  A  carefully  conducted 
herniotomy,  even  in  a  huge  inguinal  hernia  with  omentum,  small 
intestine,  and  csecum  down,  can  be  made,  with  care,  a  pi'actically 
extra-peritoneal  operation.  It  would  be  easy,  moreover,  to  show 
that  in  the  shock,  in  the  time  taken,  in  the  condition  of  the  structures 
met  with,  the  two  operations  are  scarcely  comparable. 

So  too  with  the  comi^arison  with  ovariotomy,  the  same  surgeon 
writes  :  "  Again,  in  ovariotomy,  what  are  the  dangers  there?  Mainly 
from  the  fluids  poured  out  from  adhesions  and  divided  vessels,  dan- 
gers which,  as  a  rule,  are  absent  in  gastrotomy."  I  cannot  think, 
save  in  a  few  cases,  these  operations  will  ever  run  on  parallel  lines. 
Ovariotoni}'^  is  an  operation  in  which  diagnosis  has  much  more  kept 
pace  with  operative  treatment.  In  ovarian  tumors  it  is  the  difficult 
cases,  the  delayed  operation,  which  will  more  and  more  become  the 


*  So,  too,  cases  of  Meckel's  diverticulum  will  always  be  amongst  the  most  favorable 
ones  for  operation,  from  tlie  greater  simplicity  of  the  lesion,  and  the  usually  young 
and  healthy  patient. 


654  OPEKATIOXS  ox  THE  ABDOMEN. 

exception,  in  acute  intestinal  obstruction  I  fear  the  conditions  are 
such  that  the  above  will  remain  the  rule,* 

5.  The  Failure  of  Previous  Treatment. — From  the  very  first  the  treat- 
ment sliould  be  limited  to  warmth,  enemata,  ice  to  suck,  and  only 
sufficient  morphia  to  secure  sleep  enough  to  support  the  strength  and 
to  allay  pain,  not  to  mask  important  symptoms,  and  give  a  fallacious 
appearance  of  improvement.  How  long  should  this  treatment  be 
persisted  in  ?  Each  case  must  be  decided  by  itself,  but  in  the  great 
majority  of  cases  of  acute  obstruction,  the  operation,  to  be  successful, 
must  be  performed  within  fort3^-eight  hours. 

6.  The  Condition  of  the  Patient. — If  an  operation  is  to  be  performed 
the  pulse  should  at  least  be  fair,  the  temperature  not  falling,  the  ab- 
domen not  much  distended,  and  with  sufficient  evidence  of  peris- 
talsis to  make  it  probable  that  there  is  but  little  or  no  peritonitis.  On 
the  other  hand,  when  the  patient  has  been  for  many  days  treated  by 
drugs,  the  operation  should  not  be  performed,  as  it  too  often  is,  on 
the  mere  chance  of  relief.  I  may  quote  here  from  a  previous  paper 
of  mine  :t  "  Those  who  wait,  as  I  venture  to  say  too  many  have 
waited,  till  the  abdomen  is  generally  and  enormously  tympanitic,  till 
the  temperature  is  falling  before  the  inevitable  end,  till  the  pulse  is 
running  down  and  the  patient  in  a  condition  of  irrecoverable  collapse, 
those  who  wait  till  all  or  any  of  these  things  are  present  had  far  best 
not  operate  at  all.  It  is  only  too  easy  to  foretell  the  operation  that 
follows.  The  abdominal  cavity  is  opened  readily  enough,  and  then 
the  difficulties  begin ;  coils  of  enormously  distended  intestine  at  once 
crowd  up  at  the  mouth  of  the  incision,  the  operator  has  the  greatest 
difficulty  in  finding  a  contracted  portion,  and  so  of  tracing  out  the 
point  of  obstruction  ;  perhaps,  during  his  endeavor  to  do  so,  a  fsecal 
odor  becomes  apparent,  showing  that  the  intestine  has  already  given 
way;  or,  granting  that  the  seat  of  mischief  is  found,  and  the  cause 
removed  in  spite  of  all  his  endeavors  the  surgeon  finds  himself  with 
several  coils  outside  the  abdomen,  and  at  his  wit's  end  to  get  them  in 
again,  perhaps  he  punctures  them,  but  owing  to  the  paralysis  of  the 
muscular  and  the  infiltration  of  the  serous  coat,  which  has  by  this 
time  taken  place,  tlie  puncture  in  the  mucous  coat  is  not  closed,  or 
does  not  slip  away  from  directly  beneath  the  opening  in  the  serous; 
as  the  intestine  is  returned  liquid  fseces  are  seen  escaping  at  two  or 
three  points,  any  attempt  to  close  these  with  sutures   only  makes 

*  It  would  not  be  difficult  to  show  that  the  condition  of  the  patient  before  ovari- 
otomy is  very  diflerent  from  one  submitted  to  abdominal  section  for  obstruction.  And 
with  regard  to  the  operation  itself,  in  the  one  case  the  surgeon  knows  what  to  expect; 
in  the  other  he  is  too  often  utterly  in  the  dark. 

t  Jirit.  Med.  Journ.,  September  27,  1879  :  "Case  of  Acute  Intestinal  Obstruction  by 
Bands;  Operation;  Death  Ten  Days  after." 


OPERATION    IX    ACUTE    INTESTINAL   OBSTRUCTfON.  655 

matters  worse,  and  the  joatient  sinks  quickly  after  his  removal  from 
the  table." 

Operation. — Before  proceding  to  this  the  surgeon  should  see  that 
the  following  are  in  readiness — scalpels,  probe-pointed  bistoury,  Key's 
and  ordinary  steel  directors,  six  pairs  of  Spencer  Wells'  forceps,  liga- 
tures, and  fine  sutures  of  carbolized  silk  and  chromic  gut,  absolutely 
reliable  sponges,  known  to  be  clean  beforehand,  and  soaking  for  two 
hours  in  carbolic  acid  (1  in  60),  two  of  these  should  be  flat,  two  or 
three  quarts  of  a  2  per  cent,  solution  of  boracic  acid,  kept  Avarm,  for 
irrigation  of  the  peritoneal  cavity  if  needful,  some  new  towels  cut  in 
half  and  soaked  in  warm  carbolic  solution  (1  in  60)  very  fine  needles, 
a  large  drainage-tube,  and  iodoform. 

The  bladder  is  first  emptied,  and  the  abdominal  wall  shaved  and 
cleansed  (p.  649),  The  parts  being  relaxed,  and  ether  given,  the  sur- 
geon begins  with  a  central  incision  below  the  umbilicus,  going  quickly 
down  to  the  peritoneum,  but  arrests  all  h?emorrhage  before  this  is 
opened.  If  the  linea  alba  is  not  hit  off  exactly,  and  is  not  quickly 
found,  any  muscular  fibres  are  torn  straight  through  with  a  steel 
director,  and  the  transversalis  fascia  and  peritoneum  thus  quickly 
reached. 

The  peritoneum  should  always  be  well  lifted  up  before  it  is  opened 
especially  if  there  is  distended  bowel  beneath.  The  openino-  is 
then  enlarged  for  about  2  inches  with  a  blunt-pointed  bistoury  or 
scissors,  two  fingers  with  the  palmar  aspect  turned  upwards  serving 
now  as  the  best  director.  Up  to  this  time  either  irrigation*  or  the 
spray  has  been  made  use  of,  but  are  now  stopped. 

Mr.  Greig  Smith  advises,  where  the  peritoneum  is  thin,  to  pinch  it 
up  between  the  finger  and  thumb,  and  roll  it  about  to  see  that  no 
bowel  is  included.! 

The  surgeon  should  now  decide  which  mode  of  exploration  he  will 
make  use  of.  The  following  is  as  useful  as  any.  If  the  parts  are  not 
much  distended,  these  possible  sites  of  strangulation  should  be  first 
looked  to.  The  caecum,  which  will  give  twofold  evidence,  first,  its 
distension  or  emptiness  telling  whether  the  obstruction  is  above  or 
below  it;  and  secondly,  the  state  of  its  appendix,  whether  normal  or 
free,  whether  empty  or  containing  some  concretion.  Next,  the  in- 
ternal inguinal,  the  femoral,  and  obturator  rings  are  explored,  to 
make  sure  that  no  tiny  hernia  exists  imperceptible  from  the  outside. 
The  fingers  are  next  swept  upwards  towards  the  umbilicus,  in  the 
hope  of  finding  one  of  the  diverticular  bands  mentioned  at  p.  646. 
If,  up  to  this,  the  search  has  been  fruitless,  the  brim  of  the  pelvis  is 

*  With  mercury  perchloride,  glycerin,  aniJ  water  (1  in  1000 1. 

f  If  much  fluid  i.-i  present,  it  now  often  shows  itself  through  tiie  peritoneum. 


656  OPERATIONS  ON  THE  ABDOMEN. 

next  examined,  as  bands  of  omenta  are  often  fixed  hereabouts,  and 
also  because,  in  women,  local  peritonitis,  originating  in  the  uterus  or 
its  appendages,  is,  not  unfrequently,  the  source  of  the  obstruction. 

If  the  above  search  Avith  two  or  three  fingers  fail,  and  it  often  will 
when  distension  is  present,  embarrassing  the  fingers  in  their  move- 
ments, and  obscuring  the  relation  of  parts,  one  or  two  of  the  loops 
Avhich  lie  nearest  to  the  wound  should  be  carefully  scrutinized.* 
These  should  be  followed  in  the  direction  of  increasing  congestion 
and  distension,  thus  leading  to  the  stricture.  If  it  be  needful  for 
getting  in  sufficient  fingers  to  examine  the  coils,  the  incision  must 
be  enlarged. 

If  this  second  method  fail,  there  is  nothing  for  it  but  to  draw  out  the 
most  distended  part  of  the  intestinef  under  a  new  piece  of  towelling, 
just  wrung  out  of  carbolic  acid  (1  in  60),  or  boracic  acid  (2  per  cent.), 
both  of  these  being  kept  warm.  When  there  is  not  much  distension, 
the  plan  adopted  by  INIr.  Cripps  ;|;  is  the  simplest — i.e.,  to  draw  out  some 
inches  of  intestine  at  a  time,  bit  by  bit,  from  the  upper  part  of  the 
wound,  passing  it  in  again  into  the  belly  through  the  lower  part,  in  such 
a  way  that  at  no  time  are  more  than  5  or  6  inches  of  intestine  exposed. 
After  drawing  out  and  replacing  some  feet  of  intestine  in  this  way,  it 
is  probable  that,  owing  to  the  increasing  congestion  or  resistance,  the 
surgeon  will  reach  the  obstruction. §  It  now  remains  to  take  the  dif- 
ferent causes  separately.  In  any  case  the  medium  of  strangulation 
must  somehow  be  got  into  view.  If  it  cannot  be  brought  up  into  the 
wound,  the  intestine  should  be  pressed  out  of  the  way,  to  one 
side,  and  kept  there,  if  possible,  by  a  flat  sponge,  while  the  mischief 
is  dealt  Avith. 

Bands\\  and  Aperturea^  (p.  646). — In  'most  cases  these  are  not  diffi- 

*  Mr.  Greig  Smith  says  that  as  tlie  most  distended  coils  will  rise  nearest  thesurfoce, 
and  the  greater  amount  of  bowel  is  within  three  inches  of  the  umbilicus,  there  is  a 
probability  that  the  most  dilated  coils  will  be  in  sight. 

f  I.e.,  that  part  of  it  which  is  most  inclined  to  [)rotrude  at  the  wound. 

X  Clin.  Soc.  Trans.,  vol.  xi.  p.  225. 

I  If  he  find  that  the  bowel  is  getting  healthier  and  emptier,  the  surgeon  must  re- 
verse the  direction  of  his  search.  Mr.  Cripps,  finding  that,  as  at  first  the  intestine  was 
drawn  more  and  more  from  the  leftside,  he  was  approaching  the  duodenum,  and  believing 
that  the  obstruction  was  low  down  in  the  small  intestine,  reversed  his  process  of  ex})0sure. 

II  As  stated  at  p.  053,  some  of  these,  notably  Meckel's  diverticula,  may  be  expected 
to  give  a  large  percentage  of  successes. 

\  An  excellent  instance  of  this  form  of  obstruction  has  been  recently  published  by 
Mr.  H.  Marsh  {Brit.  Med.  Joura.,  June  2,  1888).  Here  a  loop,  probably  in  the  middle 
of  the  jejunum,  had  slipped  through  a  hole  in  the  mesentery.  Tiie  mesentery  at  this 
spot  seemed  of  normal  thickness  and  pliability,  and  tlie  edge  of  the  opening  was  so 
yielding  that  Mr.  Marsh  could  readily  stretch  it  with  his  finger-nail  sufficiently  to 
allow  the  loop  to  be  drawn  out.  The  patient  made  a  good  recovery,  though  in  much 
danger,  for  a  while,  from  the  paralyzed  condition  of  the  damaged  intestine. 


OPERATION    IN   ACUTE    INTESTINAL    OBSTRUCTION.  657 

cult  to  deal  with.  If  bands  do  not  give  way  to  the  finger  as  attempts 
are  made  to  hook  them  uj),  they  should  be  divided  between  two  liga- 
tures of  chromic  gut.  Occasionally  transfixion  is  required.  Intricate 
kinking  of  loops  may  be  most  baffling.  When  one  band  has  been  dis- 
covered, the  possibility  of  a  second,  attached  to  the  pelvic  brim,  must 
always  be  remembered  (p.  653). 

Volvulus  (p.  646). — If,  as  will  probably  be  the  ease,  attempts  at  re- 
ducing this  fail,  it  should  either  be  opened,  emptied,  and,  the  aperture 
being  closed  with  a  Lembert's  suture,  fresh  attempts  at  untwisting 
made,  or  a  left  or  right  colotomy  performed,  though  it  is  very  doubtful 
if  this  opening  the  bowel  above  will  be  sufficient,  unless  the  volvulus 
itself  is  em  jD tied. 

Intussusception. — This  has  been  already  fully  dealt  with  (p.  647). 

Gallstones. — If  one  of  these  were  discovered  blocking  the  intestine, 
and  resisting  all  attempts  to  pass  it  into  the  large  bowel,  the  loop  being 
drawn  outside,  and  the  stone  extracted,  the  opening  must  be  most  care- 
fully closed.* 

The  cause  being  removed,  it  remains  to  replace  any  loops  of  intestine, 
which  if  left  outside  have  been  kept  warm  by  an  assistant,  to  clean  the 
peritoneal  cavity,  and  close  the  abdominal  wound.  A  very  important 
point  raised  by  Mr.  Greig  Smith  (lac.  supra  cit.,  jj.  378)  now  claims 
attention.  To  quote  his  own  words :  "  It  is  not  always  proper  to  return 
distended  intestine  into  the  abdominal  cavity.  I  hold,  on  the  contrary, 
that  no  operation  for  intestinal  obstruction  is  properly  completed  if 
the  patient  leaves  the  table  with  a  greatly  distended  abdomen.  The 
effects  of  distension  are  doubly  deleterious,  on  the  system  generally, 
and  on  the  bowels  themselves.  That  dyspnoea,  palpitation,  and  what 
may  be  called  abdominal  shock,  follow  great  distension  of  the  abdo- 
minal cavity  is  well  enough  known.  That  paralysis  may,  and  does, 
follow  over-distension  of  a  viscus  such  as  intestine  ....  is  also  known. 
But  it  is  not  generally  recognized  that  the  mere  presence  of  an  excess 
of  fluid  or  gas  in  the  intestine  is  in  itself  an  efficient  cause  of  obstruc- 
tion. When  the  intestine,  confined  by  mesentery  in  the  limits  of  the 
abdominal  cavity,  is  fully  distended,  it  does  not  form  gentle  curves  but 
acute  flexures.  At  these  flexures  the  intestinal  walls  on  the  mesenteric 
side  encroach  on  the  lumen,  so  as  to  form  valves  which  obstruct  the 
passage  of  contents The  disappointing  results  of  simple  tap- 
ping of  the  bowels  is  thus  explained  ;  the  gut  is  emptied  down  to  the 
second  or  third  flexure  and  no  further To  open  the  bowel,  it  is 

*  In  one  case  {Brit.  Med.  Joum.,  May  31,  1879),  after  the  removal  of  a  concretion 
from  llie  jejunum,  the  bowel  was  so  tliinned  that,  "although  it  was  well  stitched  with 
carbolized  catgut,"  it  would  not  hold  together.     The  patient  died  in  four  hours. 

42 


658  OPERATIONS   ON   THE    ABDOMEN. 

best  to  make  an  incision  by  a  scalpel  transversely  to  its  axis  at  the  point 
most  distant  from  the  mesentery.  A  trocar  and  cannula,  large  enough 
to  admit  outflow  with  sufficient  rapidity,  would  make  a  ragged,  bruised 
wound,  not  so  suitable  for  being  dealt  with  and  not  so  likely  to  heal 
kindly  as  a  simple  incision.  The  bowel,  perfectly  protected,  is  pulled 
a  few  inches  away  from  the  wound,  and  held  over  a  receiver,  while  an 
assistant  gently  kneads  the  sides  of  the  abdomen  to  force  the  fluids  up 
to  the  opening.  The  first  flow  of  gas  and  liquid  rushes  out  with  con- 
siderable force,  and  a  notable  diminution  in  the  size  of  the  abdomen  will 
at  once  be  apparent ;  artificial  pressure,  however,  is  wanted  to  empty 
the  rest  of  the  bowels.  Of  course  the  bowel  that  had  been  constricted 
will  have  been  carefully  examined  to  see  that  there  is  no  chance  of  its 
being  raptured  in  the  manipulation."  The  opening  is  closed  with  a 
Lembert's  suture  of  carbolized  silk. 

The  peritoneal  cavity  must  be  next  cleansed  of  any  spray*  fluid,  and 
above  all  of  any  discharges,  either  by  sponges  introduced  on  large 
Spencer  Wells'  forceps  down  into  the  pelvis  and  along  the  costo-ver- 
tebral  farrows,  or  by  irrigation  with  a  warm  solution  of  boracic  acid 
(2  per  cent.)  in  boiled  water. 

The  opening  in  the  abdominal  walls  is  then  closed  with  sutures  of 
wire,  and  silk  or  fishing-gut,  care  being  taken  to  include  the  parietal 
peritoneum,  and,  as  the  sutures  are  inserted,  to  prevent,  by  a  flat 
sponge,  any  blood  entering  the  cavity  of  the  peritoneum. 

The  advisability  of  forming  an  artificial  anus  is  alluded  to  below. 

ENTEROTOMY :  FORMATION  OF  ARTIFICIAL  ANUS 
IN  ACUTE  INTESTINAL  OBSTRUCTION. 

This  is  done,  under  two  chief  conditions,  when  the  surgeon  cannot  find 
the  site  of  stricture,  or  finds  that  he  cannot  deal  with  this  and  makes 
an  artificial  anus  on  the  middle  line,  or  when  he  decides  not  to  per- 
form abdominal  section,  but  to  relieve  the  distension,  etc.,  by  opening 
the  bowel  above  the  stricture,  usually  making  use  of  Nelaton's  opera- 
tion. Neither  is  more  than  palliative,  and  neither  should  be  made  use 
of  save  when  everything-  else  fails,  and  wlien  the  surgeon  feels  sure 
that  the  obstruction  is  low  down  in  the  small  intestine.f 

*  This  will  not  have  been  used  if  there  has  been  much  collapse  or  a  prolonged  oper- 
ation. As  little  of  the  body  surface  as  possible  should  be  exposed  to  it,  and  it  should 
never  be  allowed  to  plug  in  the  viscera.  Any  exposure  of  these  should  be  prevented, 
as  far  as  possible,  by  keeping  the  edges  of  the  wound  together,  and  by  carbolized  flat 
sponges,  and  towels  (p.  6)o). 

f  If  tiie  artificial  anus  be  high  u|)  in  tlie  small  intestine,  death  from  inanition  is 
certain. 


ENTEROTOMY:    FORMATION    OF    ARTIFICIAL    ANUS.  659 

Nelaton's*  Operation.— Right  Iliac  or  Inguinal  Enter- 
otomy. 

Operation. — The  small  intestine  may  he  opened  low  down  hy 
drawing  a  line  from  the  iimhilicus  to  the  right  anterior  superior  spine, 
taking  a  point  a  little  below  the  centre  of  this  line  as  the  middle  of  a 
vertical  incision  about  2  inches  long.  Another  method  is  in  use,  by 
much  the  same  incision  as  in  Littre's  operation — viz.,  one  parallel  with, 
and  about  1  inch  aljove,  Poupart's  ligament,  beginning  just  outside  the 
site  of  the  internal  ring  and  carried  upwards  and  outwards  towards  the 
anterior  superior  spine. 

In  either  case  the  structures  are  divided  down  to  the  peritoneum,  and 
all  hemorrhage  carefully  stopped.  In  a  weakly  patient,  it  may  be  well 
to  tear  through  the  muscles  with  a  steel  director.  The  opening  into 
the  peritoneum  should  not  be  more  than  1  or  1]  inch  long.  The  first 
piece  of  intestine  which  presents  in  the  wound,  or  the  one  which  seems 
to  be  the  most  distended,  is  drawn  into  the  wound  and  sutured  most 
carefully,  two  stitches,  if  possible,  being  introduced  at  either  end,  and 
three  on  each  side.  The  sutures  should  be  of  silk,  or  fishing-gut  and 
horsehair.  If  there  is  time,  peritoneal  apposition  should  be  ensured 
by  stitching  the  parietal  peritoneum  first  to  the  margins  of  the  wound 
by  a  few  points  of  chromic  gut.  If  possible,  some  hours  should  be 
allowed  to  elapse  before  opening  the  intestine.  If  it  is  absolutely 
necessary  to  open  it  at  once,  this  should  be  effected  with  a  small  and 
very  sharp  trocar,  the  cannula  left  in  and  plugged.  Another  means  of 
preventing  contamination  of  the  peritoneal  cavity  would  be  to  insert 
a  drainage-tube  through  the  cannula  and  thus  lead  liquid  fteces  quite 
away  from  the  opening.  Every  care  should  be  taken  to  keep  the  parts 
sweet  as  in  colotomy,  pp.  600,  601.  If  needful  later,  the  wound  must 
be  dilated  by  sponge-tents.  Especial  care  must  be  taken  to  ensure  the 
regular  wearing  of  a  plug,  and  to  prevent  any  accumulation  above  by 
regular  attention  to  the  bowels  and  by  injections. 

Formation  of  an  Artificial  Anus  in  the  Middle  Line.— This 
will  jH'obably  be  more  frequently  made  use  of  in  cases  where  the 
obstruction  cannot  be  relieved.     A  loop,  as  near  as  possible  to  the 

*  M.  N^laton,  introducing  this  operation  in  1840,  believed  that  some  obstructions 
would  relieve  themselves  in  time  if  a  temporary  outlet  emptied  the  accimiulalion 
above;  in  other  cases,  where  the  obstruction  was  malignant,  the  relief  thus  given 
would  be  sufficient  for  the  remainder  of  the  patient's  life  if  the  small  intestine  was 
only  opened  low  down,  wliile  this  sim{)le  operation  involved  much  less  shock  and 
disturbance  of  the  abdominal  contents.  While  the  above  are  true,  this  operation, 
which  is,  after  all,  only  palliative,  usually  fails,  from  what  1  have  seen,  by  leaving 
irrecoverable  mischief  behind  in  those  very  cases  to  wliich  it  is  best  suited — viz.,  acute 
obstruction  where  the  lesion  cannot  be  found  or  where  it  is  beyond  recovery.  Another 
disadvantage  is  the  large  amount  of  intestine  above  the  opening  which  may  remain 
distended  and  partly  paralyzed. 


6(iQ  OPERATIONS  ON  THE  ABDOMEN. 

disease,  l3eing  drawn  out,  the  wound  is  accurately  closed  around  this, 
and  the  bowel  is  then  stitched  in  situ  with  the  precautions  already 
given. 

OPERATIVE  TREATMENT  OF  SUPPURATIVE  PERI- 
TONITIS. 

Indications. — When  a  case  of  peritonitis  has  resisted  other  treat- 
ment, especially  if  it  show  dulness,  fluctuation  more  or  less  obscure, 
perhaps  oedema  of  the  skin,  when  the  vomiting  is  so  constant  that 
the  patient's  condition  is  becoming  critical,  the  peritoneal  cavity 
should  be  opened  and  the  collection  drained. 

This  may  be  either  diffuse  or  localized,*  and  the  treatment  will 
vary  accordingly.  The  peritoneal  cavity  being  opened  by  an  in- 
cision,! either  over  any  localized  dulness,  oedema,  etc.,  or  in  the 
middle  line,  at  first  about  2  inches  long,  Avhen  the  collection  is 
reached,  pus  will  come  out  freely,  often  foul  and  of  varying  consis- 
tency. It  must  all  be  removed,  if  possible,  by  varying  the  patient's 
position,  irrigation  with  a  2  per  cent,  solution  of  boracic  acid  in 
boiled  water,;}:  till  all  runs  out  clear,  and  by  introducing  sponges  on 
holders  or  in  clamp-forceps.  Every  gentleness  must  be  used,  as  the 
peritoneum  is  soft  and  altered,  and  bleeds  readily.  The  question  will 
next  arise,  if  the  pus  is  here  and  there  dammed  up  in  pools  by  coils 
of  adherent  intestine,  how  far  it  will  be  wise  to  break  these  down  and 
drain  all  the  fluid  away  once  for  all.  This  must  chiefly  depend  upon 
these  points — (a)  The  age  and  condition  of  the  patient ;  (h)  the  strength 
of  the  adhesions  ;  (c)  the  character  of  the  pus  as  to  foulness,  etc. 

In  doubtful  cases  it  will  be  wiser  to  follow  the  advice  of  Mr.  Greig 
Smith  (loc.  stipra  cit.,  p.  441)  :  "  It  is  possible,  as  I  can  from  experi- 
ence testify,  to  do  too  much  at  first  in  these  cases.  The  shock  of 
cleansing  the  abdomen  and  breaking  down  adhesions  may  at  once 
kill  the  patient,  where  waiting  a  clay  or  two,  w^hile  the  advantage  of 
evacuating  pus  is  having  its  beneficial  effect,  may  give  the  patient  an 
opportunity  of  rallying  a  little.  When  a  little  improvement  shows 
itself,  abdominal  irrigation  may  be  instituted,  and  if  there  is  a 
removable  cause,  this  may  be  treated  later  on.  I  am  convinced  that, 
in  the  most  severe  cases  of  purulent  peritonitis,  the  safest  proceeding 
is  to  treat  by  stages,  and  not  at  one  operation." 

If  the  collection  is  an  encysted  one,  it  may  not  be  found  at  once 

*  It  is  of  importance  for  the  surgeon  to  remember  the  cliief  causes— e.g.,  some  per- 
I'oration  of  a  hollow  viscus,  mischief  starting  in  the  appendix,  or  uterus,  or  ovaries, 
or  following  an  exanthem,  injury,  or  chill. 

t  The  urine  should  be  first  drawn  off,  and  the  best  anaesthetic  will  be  ether. 

X  AViih  the  condition  of  peritoneum  met  with  this  will  probably  be  preferable  to 
carbulic-acid  or  mercury-perchloride  solutions,  for  fear  of  absorption. 


CLOSURE    OF    ARTIFICIAL    ANUS.  661 

especially  if  the  median  incision  is  made  use  of.  When  the  collection 
is  found  by  the  finger,  it  should,  if  possible,  be  opened  in  situ,  and 
the  median  wound  closed,  so  as  to  keep  the  general  peritoneal  cavity 
sweet* 

If  an}'  cause  of  the  peritonitis,  such  as  ulcer  of  the  intestine  or 
perforated  appendix  ca^ci,  is  found,  it  must  be  treated.  The  ulcer 
should  be  closed  by  tying  up,  or  by  Lembert's  suture  (p.  665)  after 
paring. 

Tlie  appendix,  if  ulcerated,  should  be  removed,  and  the  end  liga- 
tured, the  serous  coat  being  drawn  over  the  others,  and  sutured 
separately  if  feasible. f 

After  the  removal  of  the  pus,  a  large  drainage-tube  should  be 
inserted,  and  the  Avound  closed,  and  every  attempt  made  to  support 
the  patient's  strength  b}'- judicious  feeding  and  opiates. 

CLOSURE  OF  ARTIFICIAL  ANUS. 
Indications. — Cases  where  the  opening  dates  to  injury,  hernia, 
etc.,  and  admits  of  being  safely  closed;  when,  owing  to  its  site  being 
high  up  in  the  intestine,  serious  marasmus  is  threatened,  and  when 
sufficient  time  has  elapsed  and  enough  trouble^  has  been  taken  to 
make  it  certain  that  there  is  no  hope  of  spontaneous  closure.  The 
I)atient's  condition  and  strength  must  be  satisfactory. 

*  This  course  was  successfully  adopted  by  Mr.  Godlee  {Clin.  Soc.  Trans,  vol.  x'\x. 
p.  90).  As  no  cause  for  the  peritonitis  was  found  beneath  the  opening,  the  finger  was 
passed  down  to  the  c^cum  where  mischief  was  expected,  finding  slightly  adherent 
coils  and  giving  vent  to  fonl  pus  The  abdominal  wall  over  the  right  iliac  fossa  being 
projected  by  the  finger  passed  here  from  tlie  wound,  an  incision,  1  inch  long,  was 
made.  It  was  now  found,  on  e.xploring,  that  the  pus  came  from  the  neighborhood  of 
the  appendix,  which,  though  thickened,  was  not  ulcerated,  and  contained  no  concre- 
tion.    The  patient  made  a  good  recovery. 

t  The  case  will  not  be  forgotten  in  which  Mr.  Symonds,  at  the  suggestion  of  our 
colleague,  Mahomed,  successfully  removed  a  concretion  from  the  vermiform  appen- 
dix, the  cause  of  recurrent  typhlitis.  The  operation  was  extra-peritoneal  {Clin.  Soc. 
Trans.,  vol.  xviii.  p.  285). 

X  When  both  openings  are  easily  found,  trial  should  be  made  of  a  simple  and 
ingenious  method  of  Mr.  B  inks  {Clin  Noteg,  p.  94).  In  an  artificial  anus  in  the  groin, 
after  a  femoral  hernia,  he  introduced  a  thick  piece  of  india-rubber  tubing  int<t  the 
opening,  and  pushed  one  end  up  the  ascending  bowel  and  the  other  down  the  de- 
scending. It  was  fastened  by  silk  hanging  out  of  the  openitig.  It  was  calcidated 
that  the  pressure  of  the  tubing  against  the  projecting  spur  would  press  it  back,  and 
allow  the  faeces  to  pass  round  the  corner  without  flowing  out  of  the  artificial  anus.  At 
the  end  of  seven  weeks  nearly  all  the  faeces  passed  by  the  rectum  instead  of  by  the  arti- 
ficial anus,  this  being  reduced  to  a  sinus,  giving  vent  to  a  few  drops  of  yellowish  fluid. 
At  the  end  of  three  months  this  completely  closed.  According  to  Mr.  Makins  (Zoc. 
infra  cit ),  the  average  duration  of  Dupuytren's  method  varies  from  four  and  a  half  to 
twelve  months.  Mr,  Barker  has  suggested  the  use  of  tspeacer  Wells'  forceps  to 
destroy  the  spur- 


662  OPERATIONS  ON  THE  ABDOMEN. 

Operation. — I  know  of  no  clearer  account  than  that  of  Mr. 
Makins.*  The  skill  with  which  this  operation  was  carried  out  was 
only  equalled  by  the  thoughtfulness  Avith  which  it  was  planned. 

The  patient  was  aged  twenty-one.  The  artificial  anus,  dating  to  a 
herniotomy,  was  high  up  in  the  small  intestine,  and  opened  about  i 
inch  above  the  centre  of  Poupart's  ligament.  Here,  at  the  l^ottom  of 
a  small  pit,  the  mucous  menil^rane  of  the  intestine  was  slightly  pro- 
lapsed. The  gut  was  firmly  attached  ;  the  finger  only  passed  into  the 
npper  opening;  the  lower  could  not  be  found.  First,  the  usual 
exzematous  condition  was  very  much  improved  by  the  use  of  a  small 
shield,  and  mopping  away  of  discharge  with  absorbent  wool.  No 
food  was  given  by  the  mouth  after  the  evening  of  the  second  day 
before  the  operation,  nutrient  enemata  being  given  every  four  hours. 
During  the  day  before,  the  upper  end  of  the  bowel  was  washed  out 
with  injections  of  salicylic  lotion.  As  bile-stained  fluid  was  escaping 
from  the  fistula  an  hour  before  the  operation,  this  washing  out  was 
repeated.  IJefore  beginning  the  operation  a  bit  of  carbolized  sponge 
attached  to  string  was  passed  for  2  inches  into  the  upper  end  of  the 
bowel.  A  vertical  incision  of  2}  inches  being  made  through  the 
abdominal  wall,  the  upper  end  of  the  intestine,  normal  in  size,  was 
dissected  free  from  its  adhesions;  the  loAver  end  lying  just  below  it 
was  contracted  to  the  size  of  a  pencil,  with  an  opening  only  large 
enough  to  admit  a  director.f 

The  two  ends  of  the  gut  being  now  provisionally  clamped  with 
forceps  (Fig.  104),  sheathed  in  tubing,  they  were  drawn  out,  and  a 

Fig.  104. 


Mr.  Makins'  clamp-forceps,  for  use  in  resection  of  intestine.  J 

number  of  sponges  attached  to  string  packed  round  them.  The 
sponge  was  then  drawn  from  the  upper  end  of  the  intestine,  and 
about  1  inch  removed  from  the  upper  end  and  11  from  the  lower  one, 
together  with  a  wedge  of  mesentery  4  inches  long  by  f  inch  wide. 
The  cut  surfaces  then  nearly  corresponded.  The  bleeding  points 
having  been  tied  in  the  mesentery,  this  was  united  with  six  silk 

*  St.  Thomas's  Hosp.  Reports,  vol  xiii.  p.  18. 

f  Over  two  months  had  ehipsed  since  the  formation  of  the  fistula,  and  one  month 
since  the  la^t  proper  action  of  the  bowels. 

X  Mr.  Makins  prefers  these  clamps  as  less  cnmhrous  than  any  others.  If  fingers 
are  used,  the  compression  varies  a  good  deal,  and  dries  and  damages  the  intestine.  If 
a  temporary  ligature  of  catgut  is  made  use  of,  and  passed  through  the  mesentery,  it 
puckers  the  bowel  and  prevents  even  stitching. 


E^"TEKOTOMY — COLLECTOMY.  663 

sutures,  and  the  gut  then  sutured  as  follows :  A  first  row  of  twenty- 
five  very  fine  China-twist  stitches  were  passed  with  a  small  curved 
needle  through  the  whole  thickness  of  the  gut  about  ^  inch  from  its 
free  margin,  commencing  at  tlie  mesenteric  border.  These  were  tied 
in  batches  of  five  at  a.  time.  Then  a  second  row  of  Lembert's  sutures 
(Figs.  106,  107)  were  passed  and  tied  in  the  same  manner.  During 
the  stitching,  which  took  about  three-quarters  of  an  hour,  the  gut  was 
kept  moist  with  warm  salic^ylic  lotion.  After  the  bowel  was  closed 
and  returned,  it  was  found  impossible  to  close  the  whole  wound.  As 
this  could  only  be  brought  together  above  and  below,  the  granulations 
were  shaved  away  and  the  intestine  left  at  the  bottom  of  a  deep  pit. 
Iodoform  gauze  and  pine-wood  dressing  were  applied.  The  patient 
made  a  good  recovery.  Two  days  later  the  intestine  could  be  seen  at 
the  bottom  of  the  wound  covered  with  l3anph  and  showing  vermicular 
movements.  The  bowels  acted  naturally  two  days  after  the  oi3eration. 
No  faeces  came  by  the  wound,  but  twelve  sutures  were  thus  discharged. 

ENTERECTOMY— COLECTOMY. 

Indications. — Many  of  these  must  be  considered  unsettled.  While 
for  artificial  anus  in  such  a  case  as  that  of  Mr.  Makins,  where  such 
conditions  are  present  as  those  of  increasing  marasmus  in  an  other- 
wise health}"  patient,  or  in  cases  of  limited  injury  to  the  gut,  the 
operation  may  be  unhesitatingly  entertained  ;  it  is  otherwise,  I  think, 
in  many  of  the  other  cases  in  which  it  has  been  performed — viz.,  gan- 
grenous intestine  and  malignant  disease.  These  are,  it  seems  to  me, 
instances  of  the  way  in  which  modern  surgery  has  planned  and 
carried  out  operations  which  have  got  far  in  advance  of  the  strength 
of  our  patients.  Where  gangrenous  intestine,  as  after  hernia  or  intes- 
tinal obstruction,  is  met  with,  owing  to  the  critical  condition  of  the 
patient,  and  the  unsatisfactory  condition  of  the  intestine  in  the 
vicinity  of  the  resection,  no  more  should  be  attempted  than  the 
formation  of  an  artificial  anus,  the  two  ends  of  the  gut  being  brought 
outside,  and  their  union  left  to  another  date. 

Again,  in  malignant  disease,  do  the  published  cases  show  that  it  is 
worth  the  patient's  while,  save  in  a  few  most  exceptional  cases,  to 
undergo  the  great  risk  of  resection,  while  the  probability  is  so  great 
that  glandular  enlargement  or  other  deposits  are  present,  and  while 
there  is  abundant  and  certain  evidence  that  colotomy,  if  performed 
in  time,  gives  such  distinct  prolongation  of  life  and  such  marked 
relief?  It  must  not  be  forgotten  that  in  many  of  these  cases  of  resec- 
tion of  the  intestine  for  malignant  disease  the  surgeon  will,  partly  from 
the  extent  he  has  been  obliged  to  remove,  partly  from  the  condition 
of  his  patient,  be  obliged  to  complete  his  operation  in  two  stages,  with 
a  prolonged  interval  between  them,  and  that,  if  secondary  deposits 


664  OPERATIONS    ON    THE    ABDOMEN. 

are  present,  the  time  for  the  completion  of  the  operation  may  never 
come,  and  thus  the  patient,  having  run  a  greatly  increased  risk,  will 
be  in  no  better  condition  than  if  he  had  only  been  submitted  to  (H)lot- 
omy. 

I  propose  first  to  describe  the  operation  as  suited  to  any  of  the 
above  conditions,  and  then  to  give  the  difficulties  and  contra-indica- 
tions. 

Operation. — This  will  include : 

1.  The  Incision. — The  site  of  this  must  vary,  as  it  is  impossible  to 
lay  down  a  definite  rule  here.  Thus,  (a)  Mr.  Bryant*  successfulh'^ 
performed  colectomy  through  a  colotomy  incision,  and  where  the 
disease,  in  this  position,  is  so  limited,  this  is  no  doubt  the  right  course 
to  pursue.  Time  alone  will  show  how  many  cases  of  malignant  disease 
are,  both  in  position  and  limitation,  suitable  cases;  I  fear  but  few. 
{b)  The  incision  in  the  linea  alba :  this  has  the  advantage  of  affording 
an  opportunity  to  explore  in  doubtful  cases,  of  giving  room  by  allow- 
ing of  extensive  enlargement,  and  of  thus,  perhaps,  reaching  secon- 
dary deposits  in  the  glands,  (c)  An  incision  over  the  growth,  as  in 
the  right  or  left  inguinal  regions,  or,  as  suggested  by  Mr.  Whitehead,t 
as  a  convenient  compromise  between  these  and  that  in  the  linea  alba, 
an  incision  along  the  outer  border  of  the  rectus. 

2.  Isolation  of  the  Growth. — By  whatever  incision  the  growth  is 
exposed,  the  surgeon  will  next  have  to  decide  whether  isolation  is 
feasible.  He  may  find  a  growth  isolated  and  apparently  free  from 
secondary  deposits,  and  thus  suitable  for  resection,  but  so  fixed  as  to 
make  it  impossible  to  bring  it  up  into  the  wound  by  any  amount  of 
traction  that  can  be  called  safe.  In  such  a  case  the  operation  had 
best  be  abandoned,  and  colotomy  substituted  in  the  case  of  the  large 
bowel.  Other  indications  for  abandoning  resection  will  be  glandular 
enlargement,  if  at  ail  extensive,  and  adhesions  of  the  affected  intestine 
to  neighboring  parts. 

3.  Resection  of  the  Intestine. — If  it  be  found  possible  to  bring  up  the 
intestine  into  the  wound,|  and  feasible  to  resect  it,  sponges  are  care- 
fully packed  all  around  so  as  to  shut  off  the  peritoneal  cavity,  and  the 
bowel  is  occluded  just  above  the  intended  sites  of  section,  either  by 
the  fingers  of  an  assistant  or  by  clamps.  Of  these,  Mr.  Makins'  (Fig. 
104)  seem  as  simple  and  efficient  as  any.  The  diseased  portion  is  then 
cut  away  with  a  triangular  wedge  of  mesentery,  the  base  correspond- 
ing exactly  to  the  part  of  bowel  removed.  Any  vigorously  bleeding 
points  are  now  tied  with  fine  catgut,  and  the  edges  of  the  mesentery 

*  Med.  Cliir.  Trans  ,  vol.  Ixv.  p.  131. 
f  Brit.  Med.  Journ.,  January  24,  1885. 

X  The  softened  condition  of  tlie  bowel  at  the  site  of  disease,  the  varying  length  of 
the  meso-colon,  etc.,  must  be  borne  in  mind. 


SUTURE    OF    THE   INTESTINE. 


665 


brought  together  with  continuous  or  separate  points  of  suture  of  the 
same  material. 

4.  Suture  of  the  Intestine. — After  resection  of  the  intestine  and  mesen- 
tery, the  ends  of  the  cut  bowel  are  carefully  emptied,  cleansed,  and 


Fig. 105. 


This  shows  the  appearance  of  a  completely  resected  bowel  with  its  edges  much  everted  prior 
to  the  Introduction  of  sutures.  Four  stitches  have  been  inserted  in  the  mesentery  to  join  its 
two  cut  edges.    (MacCormac.) 

brought  into  apposition,  a  point  of  some  difficulty  owing  to  the  ever- 
sion  of  the  mucous  membrane  (Fig.  105).  Of  the  numerous  forms  of 
sutures,  most  have  become  obsolete. 

Two  modes  only  will  be  described  here.     In  one  a  double  row  are 
inserted  ;  the  first,  being  tied  within,  take  up  the  mucous  membrane 


Fig. 106. 


Fig.  107. 

\  : 


Five  sutures  introduced  by  Lembert's 
method.    (MacCormac.) 


Lembert's  suture,  as  used  by  Sir 
W.  MacCormac  in  two  successful 
cases  of  intra-peritoneal  rupture  of 
the  bladder. 


only.     Fig.  107  shows  their  mode  of  introduction.     An  external  line 
of  sutures  is  then  applied  after  Lembert's  method.     Each  of  these 


666  OPERATIONS   ON    THE    ABDOMEN. 

should  be  inserted  not  less  than  h  inch  from  the  cut  edge,  run  along 
in  the  muscular  or  between  the  muscular  and  serous  coats ,  it  is  then 
made  to  emerge  just  wide  of  one  ciit  edge,  re-inserted  just  beyond  the 
opposite  edge,  then  at  once  made  to  travel  between  the  coats  and  to 
emerge  as  before.  This  method  has  the  advantage  of  turning  in  and 
keeping  in  contact  the  peritoneal  membrane  which  bounds  the  edges 
on  either  side. 

In  the  other  mode  of  suturing,  the  above  suture  of  Lembert's  is 
alone  trusted  to,  without  any  internal  row  in  the  mucous  membrane. 
Sir  W.  MacCormac  thinks  that  the  single  row  is  enough,  as  long  as  a 
sufficient  width  of  surface  is  taken  up. 

Fine  Chinese  twist  silk,  thoroughly  carbolized,  is  the  best  material, 
and  a  sufficiency  of  fine  round  needles  (so  that  the  aperture  is  at  once 
plugged  by  the  thread)  should  be  at  hand.  Flat  needles,  however,  if 
only  fine  enough,  will  serve  the  purpose  well.  Different  curves  should 
be  provided,  and  two  or  three  needle-holders,  and  the  operator  must 
be  kept  well  supplied. 

One  or  two  points  require  special  attention.  The  sutures  should  be 
inserted  about  i  inch  from  each  other,  and  from  twenty-five  to  forty 
will  be  required  in  the  two  rows  together,  each  being  inserted  as  fer  as 
possible  at  an  interval  between  two  others.  The  chief  attention  is 
needed  at  the  attachment  of  the  mesentery,  the  outer  sutures  being 
dipped  here  well  into  the  muscular  coat,  so  as  to  bring  the  serous 
surface  firmly  in  contact,  and  thus  avoid  any  extravasation  into  the 
triangular  interval  which  here  exists  at  the  separation  of  the  perito- 
neum into  two  layers. 

When  all  the  intestine  is  closed,  it  is  cleansed,  and  gentle  pressure 
is  made,  after  removal  of  the  upper  clamp,  to  see  if  the  contents  pass 
beyond  the  line  of  suture  safely.  If  all  is  water-tight,  the  parts  are 
again  thoroughly  cleansed,  all  sutures  of  uneven  length  trimmed,  the 
protecting  sponges  removed,  the  neighborhood  made  clean,  and  the 
intestine  and  mesentery  returned,  having  finally  had  a  little  iodoform 
dusted  on  and  rubbed  over  it.  The  wound  is  then  closed  in  the 
usual  way. 


CHAPTER  VI. 


OPERATIVE  INTERFERENCE  IN  GUNSHOT  AND 
OTHER  INJURIES  OP  THE  ABDOMEN. 

My  space  does  not  allow  me  to  consider  separately  those  other 
causes  of  abdominal  injury  which  may  call  for  exploration — viz., 
ruptured  intestine  from  a  horse-kick,  or  a  wheel  going  over  the  ab- 


GUNSHOT   INJURIES    OF    THE    ABDOMEN.  667 

domen.      The   following   remarks  will  be  found  to  apply  to  these 
injuries  also. 

We  owe  the  great  advances  lately  made  in  this  subject,  in  the  first 
place,  to  modern  antiseptic  surgery,  and,  in  the  second,  to  the  zeal 
with  which  American*  surgeons  have  taken  up  the  matter  and  made 
known  their  results,  unsuccessful  as  well  as  successful. 

1,  Examination  of  the  Wound,  with  Regard  to  Penetration. — The  edges 
of  the  wound.  Blackening  of  this  and  the  clothes  Ayith  powder  sug- 
gests a  close  shot  and  probable  penetration.  Edges  clean  cut  and 
equally  stained  show  that  the  bullet  has  struck  perpendicularly  ;  un- 
equal staining  and  raggedness  suggest  obliquity  of  impact,  and  the 
less  perpendicular  this  is,  the  less  the  probability  of  penetration. 
If  there  exists  a  continuous  track  of  tenderness,  esijecially  if  accom- 
panied with  slight  redness,  from  the  wound  for  some  distance  over 
the  abdominal  surface,  it  is  fair  to  infer  that  the  missile  has  wormed 
itself  between  the  layers,  without  penetration  (Parkes). 

2.  Symptoms  indicating  Penetration. 

(a)  Circumscribed  dulness  and  bulging  near  the  wound,  fluctua- 
tion in  the  peritoneal  cavit}',  or  either  of  the  last  two  felt  per  rectum 
or  vaginam,  indicate  wound  of  a  large  vessel  and  accumulation  of 
blood,  and  penetration,  with  visceral  injury,  probably;  but,  to  be 
diagnostic,  it  must  come  on  within  a  couple  of  hours. 

(/?)  Kapidlyt  forming  tympanitis  indicates  penetration  and  escape 
of  gas  from  the  intestine. 

(j)  Escape  of  faeces,  bile,  or  urine  from  the  wound  is,  of  course, 
diagnostic  of  penetration,  but  rare. 

(^)  Repeated  htematemesis  indicates  penetration  and  injury  to 
the  stomach  or  small  intestine  high  up.  It  may,  however,  be  due  to 
contusion. 

(e)  Profuse  haemorrhage  per  anum  i:)oints  to  penetration  and  injury 
of  intestine,  but  is  seldom  seen  sufficiently  earl}^  to  be  of  value. 

(C)  Hsematuria  indicates  injury  of  some  part  of  the  virinary  tract. 

('/)  Escape  of  blood  from  the  wound,  if  too  profuse  to  be  accounted 
for  by  a  wound  of  a  vessel  in  the  abdominal  wall,  points  to  penetra- 
tion and  visceral  injury. 

(B)  Paralysis  of  any  part  below  the  level  of  the  wound  is  a  most 
grave  complication,  indicating,  as  it  does,  injury  to  cord  or  nerves,  as 
well  as,  probably,  to  viscera. 

(<)  Shock.      This   does   not   go   for   much    unless   haemorrhage   is 

*  In  addition  to  the  American  writers  I  have  quoted  from  below,  I  have  had  the 
advantage  of  reading  a  very  careful  study  of  this  subject  by  my  old  dresser,  Dr.  J.  H. 
Barnard,  now  of  Paris,  Des  Plates  de  I' Infest  in  par  Armes-d-feu  (These  pourle  Doctorat 
en  Medecine.     Paris.     1887). 

f  If  delayed,  the  tympanitis  may  be  due  to  paralysis  of  the  intestines  from  shock. 


668  OPERATIONS    ON    THE    ABDOMEN. 

clearly  present  also,  owing  to  the  great  difiference  in  individual 
peculiarities. 

Other  points  will  be,  tlie  size  of  the  bullet  and  amount  of  fulmi- 
native  or  powder,  the  distance  and  direction  in  which  the  firearm 
was  held.  A  single  opening  gives,  per  se,  a  faint  hope  that  there  is  no 
penetration. 

In  cases  of  doubt  as  to  penetration,  the  wound  will  be  first  ex- 
plored,* then  enlarged,  and  the  line  of  damage  to  the  tissues  care- 
fully followed  up,  any  exploring  instruments  being  kept  strictly 
aseptic. 

3.  Probable  Amount  of  Damage. — Dr.  Parkesf  gives  the  following 
suggestions :  "  An  antero-posterior  shot  below  the  level  of  the  um- 
bilicus and  well  towards  the  lateral  surfaces  of  the  body  will  be  very 
likely  to  miss  the  small  intestines  entirely,  and  expend  its  damage 
on  the  large  bowel.  The  same  kind  of  wound  high  in  the  lateral  sur- 
faces may  pass  into  or  through  the  liver  without  injuring  the  intes- 
tines, or  the  spleen  alone  if  the  entrance  is  on  the  left  side. 

"  If  the  wound  is  so  situated  that  the  bullet  enters  the  abdomen 
through  the  diaphragm,  adding  injury  of  abdominal  viscera  to  that  of 
the  contents  of  the  chest,  the  surgeon's  help  will  probably  be  of  little 
use.  A  wound  of  entrance  and  exit,  or  an  entrance  wound  alone, 
showing  passage  of  the  ball  from  side  to  side  through  the  abdomen, 
means  the  worst  of  injuries,  and  suggests  the  need  of  the  greatest 
care  in  staying  of  ha?morrhage,  repair  of  intestines,  and  toilet  of  the 
contents. 

"  Antero-posterior  perforation,  if  complete,  can  only  fail  to  wound 
the  small  intestines  when  situated  well  on  the  outskirts  of  the  sur- 
face of  the  abdomen ;  seemingly  there  can  be  no  exce^jtion  to  this 
proposition,  save  in  those  extremely  rare  instances  in  which  the  per- 
forating body  traverses  the  cavity  without  injuring  the  contents. 

"  Penetration  through  the  posterior  walls  of  the  cavity,  if  complete, 
with  likelihood  of  laceration  of  important  fixed  organs,  argues  an  in- 
jury of  the  most  severe  character,  one  in  which  the  surgeon's  aid  will 
be  of  no  avail  in  the  majority  of  cases.  The  exceptions  in  which  the 
severity  will  not  prove  insurmountable  will  be,  transit  through  the 
space  between  the  lower  end  of  the  kidney  and  the  crest  of  the  ilium, 
and  in  wounds  occupj'ing  the  outskirts  of  the  entire  posterior  sur- 
face  Many  instances  are  recorded  of  recovery  from  posterior 

penetration  of  the  large  and  fixed  viscera  of  the  abdomen  without 
any  surgical  operation  whatever." 

*  Any  probe  nsed  should  not  be  too  fine  or  sharp  pointed.  A  clean  bougie  will 
usually  be  preferable.  The  old  advice  not  to  probe  or  explore  these  injuries  must, 
nowadays,  be  considered  exploded. 

f  Ann.  of  Surg.,  November,  1887. 


GUNSHOT    INJURIES    OF   THE    ABDOMEN.  669 

Question  of  the  Advisability  of  Operative  Interference. — 

While  some  cases  of  penetrating  wounds  with  very  severe  injury  {e.g., 
perforation  of  intestine  and  wound  of  solid  viscera)  have  occasion- 
ally recovered,  the  proportion  here  is  extremely  small — Prof.  Nan- 
crede  gives  8  per  cent. ;  death  from  septic  peritonitis  or  haemorrhage  is 
so  common  as  to  justify  our  urging,  in  most  cases,  as  early  an  opera- 
tion as  is  possible.  The  exceptions  would  appear  to  be,  cases  where 
sufficient  time  has  elapsed  to  allow  of  much  extravasation  and  the 
onset  of  a  peritonitis  which  is  certain  to  be  fatal  whatever  is  done, 
cases  of  injury  to  the  spinal  cord,  severe  wounds  of  the  solid  viscera, 
and  those  where  such  grave  shock  is  present  as  to  make  it  certain 
that  the  needful  interference  with  the  contents  of  the  abdomen  will 
be  necessarily  fatal.* 

Prof.  Nancrede  {he.  sirpirt  cit.,  p.  474)  thus  states  the  advantages  of 
an  operation :  "  We  can  either  forestall  septic  peritonitis  or  reduce 
its  dangers  to  a  minimum;  we  can  prevent  saprtemia — a  common 

cause  of  death,  as  I  believe Should  peritonitis  have  set  in,  we 

can  afford  sufficient  drainage,  for  the  effusions,  which  may  in  them- 
selves be  already  poisonous,  or,  as  we  have  shown,  wall  assuredly  be- 
come the  chief  cause  of  danger;  we  can  substitute  for  adhesion  of 
doubtful  permanency  certain  methods  which  secure  the  escape  of  the 
injured  portions  of  gut  into  the  lumen  of  the  bowel ;  we  can  prevent 
the  fatal  results  which  must  follow  the  casting  off  of  a  decomposing 
slough  of  a  wounded  portion  of  omentum  or  mesentery  into  the 
general  peritoneal  cavity ;  we  can  arrest  haemorrhage,  which  from  its 
amount  will  i)rove  fatal,  or  from  decomposition  will  equall}^  produce 
lethal  result ;  we  can  res+ore  the  continuity  of  the  gut,  if  it  be  nearly  or 
completely  severed,  the  former  condition  being  not  uncommon  ;  we 
can  avoid  the  risk  of  faecal  fistula  ....  and  w^e  can  remove  a  hope- 
lessly damaged  kidney  or  spleen,  and  rejDair  a  wounded  pancreas  or 
liver." 

Operation. — An  excellent  account  of  this  will  be  found  in  the 
very  helpful  article  of  Prof.  Nancrede  to  which  reference  has  been 
already  made. 

With  the  utmost  care  the  preliminary  details  of  preparation  are 
entered  into  first — viz.,  the  cleaning  and  shaving  of  the  skin,  the  pro- 
viding of  abundance  of  water  recently  sterilized  by  boiling,  or  solu- 
tion 1  in  10,000  of  mercury  bichloride,  or  1  in  500  of  carbolic  acid, 
also  boiled.     Most  scrujjulous  cleansing  of  instruments.     Plenty  of 


*  Dr  Barnard  {Inc.  svpra  cit.,  p.  58)  quotes  Dr.  Hamilton,  of  New  York,  as  of  opinion 
tliat  operative  interference  is  contra-indicated  if  forty-eight  liours  have  elapsed  since 
the  accident. 


670  OPERATIONS  OX  THE  ABDOMEN. 

soft  old  linen,  h'ing  in  the  hot  sterilized  water,  to  cover  the  intestines 
with.     Abundance  of  ligatures  of  gut  and  silk  of  different  sizes* 

"  Now  as  to  technique.  The  patient's  limbs  and  trunk  nuist  be 
carefully  wrapped  in  blankets,  with  towels,  wrung  out  of  the  aseptic 
or  antiseptic  solution  tucked  under  and  folded  over  them  around  the 
abdomen  to  prevent  any  accidental  contamination  of  the  peritoneal 
cavity.  If  not  i^reviously  done,  the  urine  should  now  be  drawn 
off Ether  should  be  most  cautiously  administered.  The  in- 
cision should  always  be  median,  as  otherwise  it  is  almost  impossible 
to  gain  a  proper  view  of  the  parts,  and  should  usually  extend  from  a 
short  distance  above  the  umbilicus  to  about  2  inches  above  the  pubes. 
The  abdomen  having  been  opened,  any  clots  or  blood  which  obscure 
the  operating  field  may  be  removed,  but  otherwise,  unless  it  is  mani- 
fest that  severe  haemorrhage  is  going  on,  the  small  intestines,t  which 
usually  first  present,  should  be  carefully  gone  over,  inch  l)y  inch,  from 
the  stomach  to  the  ileo-ciecal  valve,  keeping  them  constantly  envel- 
oped in  towels  wrung  out  of  hot  water  (sterilized) ;  afterwards  the 
stomach,  spleen,  liver,  pancreas,  large  bowel,  kidneys,  l^ladder,  omen- 
tum, mesentery,  and  abdominal  vessels  must  be  examined.  I  do  not 
mean  that,  if  various  wounds  are  discovered,  say  in  the  small  intestine, 
and  the  place  of  exit  of  the  ball  from  the  abdominal  cavity,  all  in  such 
relations  as  would  absolutely  exclude  injury  of  the  stomach,  liver, 
kidneys,  spleen,  or  bladder,  such  a  detailed  examination  should  be 
made — far  from  it,  for  every  unnecessary  manipulation  is  injurious; 
but  I  do  advise  that,  rather  than  overlook  a  wound,  much  manipula- 
tion which  the  result  proves  to  have  been  unnecessary  had  better  be 
made.  Of  course  the  source  of  a  severe  ha'morrhage  must  be  at  once 
sought  for,  and  any  wounds  of  the  hollow  viscera  ignored  for  the  time 
being,  care,  however,  being  taken  that  the  general  peritoneal  cavity  is 
protected  from  fsecal  extravasation  by  removing  the  intestines  outside 
the  abdomen,  keeping  them  wrajjped  in  warm,  moist  cloths  ;  such 
haemorrhage  is,  however,  most  unusual.  Whichever  plan  is  pursued, 
let  everything  be  done  methodicallj^,  and  each  injury  repaired  as  it  is 
detected,  as  this  saves  much  time  and  renders  any  oversight  almost 
impossible.  All  wounds  of  the  bowel,  however  trivial,  should  be 
minutely  cleansed,  coaptated  by  the  Lembert  suture  of  fine  silk  intro- 
duced with  an  ordinary  sewing-needle,  and  the  suture  line  rubbed 
over  with  a  little  iodoform.  When  necessary  from  the  size  or  number, 
of  the  wounds,  a  portion  or  whole  calibre  of  the  gut  must  be  exsected. 
Wounds  of  the  liver,  if  situated  at  the  free  border  of  the  organ,  should, 

*  The  temperature  of  the  operating-room  will  have  been  attended  to 

f  Dr.  Barnard  {loe.  supra  cit.)  points  out  that  wounds  of  the  duodenum  are  very 

rare)  V  met  with,  and  that  wounds  of  the  upper  aspect  of  the  transverse  colon  and  of  the 

omentum  at  this  level  are  amongst  the  most  difficult  to  discover. 


GUNSHOT    IXJURIES   OF    THE    ABDOMEX.  671 

if  possible,  be  coaptated  with  dry  aseptic  gut,  which  will  soon  swell 
and  fill  the  track  made  by  the  needles.  If  this  cannot  be  done,  the 
hsemorrhage  may  perhaps  be  arrested  by  the  judicious  use  of  the  ther- 
mo-cautei'y.  Unless  the  bleeding  be  free,  the  wound  should  be  plugged 
with  an  iodoform-gauze  tampon,  which  is  to  remain  permanently, 
or  may,  perhajDS,  be  carefully  removed  at  the  close  of  the  operation, 
when,  if  the  bleeding  be  almost  entirely  checked,  the  cautery  may  then 
be  used  as  a  further  precaution  ;  if  the  flow  be  free,  the  tampon  must 
be  replaced  and  allowed  to  remain  permanently. 

"  AVounds  of  the  pancreas,  spleen,  or  kidneys  (p.  628)  must  be  treated 
in  a  similar  manner,  or,  if  these  measures  fail,  either  spleen  or  kidney 
must  be  excised.  Since  a  wounded  splenic  artery  would  lead  to  gan- 
grene of  the  organ,  it  must  be  removed.  The  same  advice  holds  good 
for  wound  of  a  renal  artery,  but  in  these  cases  death  from  ha?morrhage 
Avill  usually  result  before  art  can  intervene;  still,  such  possible  com- 
plications must  be  provided  for.  Wounds  of  the  bladder  had  best  be 
sewn  with  dry  chromic  and  sulphurous  acid  gut,  which,  by  its  swell- 
ing, will  fill  the  track  of  the  little  wounds ;  and  the  needle  should  be 
a  round  one,  as  small  as  can  be  made  to  carry  the  thread.  Contused 
bowel  will  .almost  certainly  slough,  so  that  the  injured  portion  had 
better  be  excised  and  the  healthy  peritoneal  surfaces  united  by  suture. 
Wounded  or  contused  omentum  or  mesentery  must  also  be  excised, 
and  the  edges  carefully  united  by  interrupted  sutures.  The  experience 
of  at  least  one  case  has  shown  that  since  an  omental  slough  cannot  be 
eliminated  into  the  lumen  of  the  bowel,  as  occurs  in  wounds  of  the 
intestine,  a  fatal  generalized  peritonitis  will  result  from  the  local  gan- 
grene. All  bleeding  must  be  checked,  even  from  the  smallest  vessels, 
for  quite  extensive  oozing  will  occur. from  most  insignificant  vascular 
orifices,  because  they  are  situated  in  a  closed  cavity,  and,  although 
the  amount  lost  may  not  be  dangerous  per  se,  it  will  prove  so  as  a 
source  of  septicaemia  or  peritonitis. 

"  If  a  segment  of  bowel  is  to  be  excised,  the  cuts  should  be  made  at 
such  points  as  correspond"  to  the  distribution  of  a  large  mesenteric 
branch,  in  order  to  secure  a  due  blood-supply  to  the  edges  of  the  in- 
cisions, and  the  parts  to  be  removed  should  be  laid  upon  a  large  flat 
sponge,  or  folded  napkins,  to  prevent  fiecal  extravasation  into  the 
abdominal  cavity.  To  obviate  kinking  of  the  bowel,  a  V-shaped  piece 
of  the  mesentery  must  be  removed,  the  branches  of  the  V  not  corre- 
sponding to  the  cut  edges  of  the  bowel,  but  presenting  a  free  margin 
of  8  inch,  lest  want  of  vascularity  cause  failure  of  union  at  this  the 
most  doubtful  point.  After  arresting  hemorrhage,  the  mesenteric 
wound  must  be  carefully  coai:)tated  b}'  numerous  points  of  interrupted 
suture. 

"  Should  the  pulse  fail  at  any  time  during  the  operation  owing  to 


672  OPERATIONS  ON  THE  ABDOMEN. 

irritation  and  paresis  of  the  abdominal  sympathetic,  flushing  the 
intestines  and  peritoneal  cavity  witli  hot  water  will  often  at  once 
remove  the  unfavorable  condition.  The  most  scrupulous  care  must 
be  exercised  in  the  peritoneal  toilet,  Avhich  can  be  most  quickly  and 
effectively  made  by  thorough  irrigation  of  the  cavity  with  warm  steri- 
lized water  and  subsequent  careful  removal  of  all  fluid  in  the  ordinary 
manner  by  sponges,  especial  attention  being  paid  to  the  case  of  the 
pelvis  and  the  renal  regions. 

"  When  possible,  the  peritoneum  should  be  united  over  the 
orifices  of  entrance  and  exit  of  the  ball,  and  a  little  iodoform  rubbed 
in 

"  When  incipient  peritonitis  exists  at  the  time  of  operation,  Avith  the 
probable  formation  of  large  quantities  of  acrid  septicaemia  or  saprremia 

inducing  serum,  drainage  should  in  all  cases   be  instituted 

The  tube,  preferably  of  glass,  should  have  its  end  kept  Avell  down 
between  the  bladder  and  rectum  in  the  male,  or  in  Douglas's  cul-de- 
sac  in  the  female,  with  the  external  orifice  plugged  with  iodoform 
cotton." 

Prof.  Nancrede's  remarks  on  the  chief  points  in  the  after-treatment 
will  well  repay  perusal.  Rectal  feeding  for  forty-eight  hours.*  Peri- 
odic emptying  of  the  drainage-tube  with  a  syringe,  or  even  irrigation 
through  it.  Morphia  injections,  combined  with  atropia  (about  eVg^O 
rather  than  opium.  Cold  to  abdomen  by  means  of  ice  coil.  These 
and  many  others  are  well  discussed. 

The  following  details  are  the  outcome  of  experiments  by  Dr.  Parkes.f 
They  have  already  laid  foundations  for  much  good  work.  "  There 
was  no  reason  to  suppose  that  the  extent  of  the  incision  added  much, 
if  at  all,  to  the  gravity  of  the  operation.  After  opening  the  abdomen, 
the  intestines  were  all  turned  out,  critically  examined  for  perforation 
or  contusion,  the  situation  of  these  fixed,  and  the  haemorrhage  there- 
from controlled  by  means  of  the  snap-forceps,  after  which  wounds  of 
special  organs  were  sought  for.  If  the  substance  of  the  spleen  or  the 
kidney  was  found  perforated,  the  organ  was  immediately  removed 
after  ligating  its  bloodvessels,  the  stump  being  returned.  If  slight 
lacerations  only  at  some  point  on  the  surface  had  been  produced, 
these  were  closed  by  bringing  the  peritoneal  surfaces  of  the  organ  over 
the  wound  by  the  continued  suture.  The  peritoneal  sac  was  then 
carefully  and  thoroughly  cleared  of  blood,  etc.,  by  repeated  sponging 
or  irrigation.  The  intestines,  which,  during  this  process,  had  been 
protected  by  being  enveloped  in  towels  wrung  out  of  warm  water, 
were   now   cleanly   sponged,   while    all   unwounded    portions    were 

*  The  passage  of  a  long  tube  may  bring  aboiil  the  escape  of  flatus,  and  so  give  great 
relief. 

f  Ounshot  Wounds  of  the  Small  Intestines.     Chicago:  1884.     Dogs  were  the  patients. 


GUXSHOT    INJUEIES   OF    THE    ABDOMEN. 


673 


returned  into  the  abdomen Where  several  wounds  occurred 

rather  close  together,  and  were  enough  to  destroy  a  considerable  por- 
tion of  the  integritj^  of  the  bowel,  one  resection  was  made  to  include 
all  of  them,  even  when  the  length  removed  measured  10  inches  or 
more.     Where  the  points  of  injury  were  widely  separated  from  each 


Fig.  109. 


Fio.  108. 


Multiple  bullet  wounds  (ten  complete  per- 
forations) in  18  inches  of  ileum.  A  good  instance 
of  a  class  of  cases  most  difficult  to  manage  and 
fatal  in  their  results.    (Parkes.) 


To  the  left  a  bullet  wound  is  shown  pared, 
with  six  Lembert's  sutures  in  position 
ready  for  tying.  To  the  right  the  entire  cir- 
cumference of  the  bowel  is  shown,  so  man- 
gled as  to  require  resection.    (Parkes.) 


other,  and  extensive  damage  done  at  each  point,  several  resections  of 
a  length  of  the  tube  just  sufficient  to  include  the  injured  portions  were 
made.*  In  the  former  case,  in  which  several  inches  of  the  tube  were 
taken  awa}',  the  mesentery  was  ligated  as  close  as  practicable  to  the 
intestine  (Fig.  Ill)  in  sections  corresponding  to  the  number  of  vessels 
going  to  the  resected  portions.  The  mesentery  was  then  divided  close 
to  the  intestine,  and  a  V-shaped  portion  of  it  removed.  After  this  the 
tube  itself  was  divided  and  the  wounded  portion  removed.  One 
artery  always  needing  ligation  was  found  in  the  divided  ends  at  the 
point  of  junction  of  the  mesentery  with  the  intestine.  Before  the  final 
division  of  the  intestine,  its  contents  were  pushed  back  out  of  the  way, 
compression  exercised  on  its  walls  by  forceps  or  temporary  ligature. 
....  The  safest  comi^ressionf  can  be  made  b}^  an  assistant's  fingers 
(p.  662,  Fig.  105). 

"Results  soon  demonstrated  the  paramount  necessity  of  carefully 
selecting  the  place  for  final  division  of  the  intestine,  in  order  to  avoid 

*  It  seems  probable  that  the  greatest  success  will  follow  a  single  resection,  even  if 
that  include  a  number  of  perforations,  and  involve  8  or  10  inches  of  the  gut,  in  com- 
parison with  those  cases  where  several  excisions  are  made  of  wounded  parts  widely 
separated. 

t  The  constriction  mark  made  by  the  forceps  or  ligature  was  to  be  plainly  seen 
several  days  after  the  operation. 

43 


674  OPERATIONS   ON   THE   ABDOMEN. 

sloughing  of  the  edges,  the  results  being  best  in  those  cases  where  the 
division  was  made  close  to  the  point  at  which  any  given  mesenteric 
artery  a]jproached  nearest  to  the  intestine,  as  compared  with  those 
where  the  cut  was  made  in  the  intervals  between  any  two  branches, 
and  this  was  seemingly  dependent  on  the  better  supply  of  blood. 
Immediately  after  division  of  the  intestine,  there  followed  a  regular 
and  considerable  contraction  of  the  calibre  of  the  tube  close  up  to  the 
divided  edge,  caused  by  the  contraction  of  the  circular  muscular  fibre. 
This  persisted  for  a  time,  but  was  soon  followed  by  an  aversion  of  the 
mucous  membrane,  which  rolled  out  and  over  the  constricted  portion 
in  a  remarkable  manner  (Figs.  108,  110,  111).  This  protrusion  forms 
a  serious  obstacle  to  easy  and  close  approximation  of  the  ends  of  the 
bowel;  and  when  turned  into  the  bowel,  diminishes  its  calibre  con- 
siderably, although  it  was  not  demonstrated  that  the  obstruction  was 
ever  sufficient  to  prevent  the  passage  of  the  intestinal  contents.  Sev- 
eral attempts  were  made  to  get  rid  of  it,  but  all  these  were  finally 
abandoned.* 

"  In  all  instances  where  a  perforation  was  severe  enough  to  require 
a  resection  of  the  wounded  part,  it  was  found  advantageous  to  leave, 
if  possible,  a  strip  of  the  bowel  near  the  mesenteric  junction  (Fig.  110), 
taking  out  the  wounded  portion  by  a  V-shaped  incision.  The  part  left 
acted  as  a  support  to  the  wound,  avoided  division  of  the  bloodvessels, 
opposed  the  action  of  the  longitudinal  fibres,  and  in  no  instance  in 
which  this  plan  was  adopted  was  there  any  appearance  of  separation 
of  the  wound.f  ....  Perforations  through  the  mesenteric  surface  of 
the  intestine  were  the  most  difficult  to  treat,  and,  even  if  slight,  seemed 
always  to  require  a  complete  excision.  A  partial  excision  of  this  sur- 
face of  the  bowel  resulted  in  an  acute-angled  elbow  which  never  did 
well.  The  point  of  attachment  of  the  mesentery  with  the  bowel  will 
usually  be  found  the  most  troublesome  to  manage  in  applying  the 

sutures  in  restoring  a  complete  division The  difficulty  arises 

apparently  from  the  manner  in  which  the  folds  of  peritoneum  separate 
from  each  other  before  passing  on  to  invest  the  bowel,  leaving  a  little 
triangular  interval  filled  with  loose  connective  tissue,  fat,  and  vessels. 


*  Tlius  "  it  was  pared  away  with  scissors ;  it  was  dissected  up  from  the  other  coats  for  ^ 
inch  from  the  edges;  but  the  conchision  was  finally  readied  that,  instead  of  being  a 
harm,  its  presence  was  useful  in  giving  support,  protection,  and,  perhaps,  vascularity 
to  the  freshly  sutured  edges;  at  least,  in  all  instances  where  it  was  removed  the  stitches 
were  found  torn  out  and  union  defeated;  in  no  instance  where  it  was  left  entire  did 
there  fail  to  be  union  in  some  part,  and  no  sutures  gave  way  when  properly  applied." 

f  Dr.  Parkes  found  that,  in  small  perforations  of  the  stomach  and  intestine,  the  case 
did  well  after  drawing  the  peritoneal  surfaces  some  distance  from  the  edges  thereof 
over  it  by  a  continued  suture,  thus  converting  it  into  a  linear  wound.  He  thinks  this 
plan  may  safely  take  the  place  of  excision  in  not  a  few  cases  of  quite  severe  injury. 


GUNSHOT   INJURIES   OF   THE   ABDOMEN, 


675 


Now,  if  the  suture  fails  to  include  the  muscular  coat  as  well  as  the 
peritoneum  at  this  point,  the  junction  will  surely  give  way.  To  make 
this  point  secure,  the  greatest  care  must  be  taken  in  placing  at  least 
three  sutures,  this  number  being  usually  quite  enough  to  include  the 
troublesome  area,  and  these  should  always  be  the  first  sutures  applied. 
In  completing  the  junction,  it  assists  materially,  and  especially  avoids 
trouble  from  the  everted  mucous  membrane,  to  apply  one  at  the  most 
convex  surface,  and  then  one  half-way  down  on  each  lateral  surface.  ,  .  . 


Fig.  110. 


Fig.  111. 


A  shows  the  strip  of  bowel  left  at  the  mes-  (Parkes.) 

enteric  border  (p.  674) ;  B,  the  triangular  inter- 
val where  the  mesentery  encloses  the  gut,  a  spot 
very  hard  to  close.    (Parlies.) 

The  greatest  number  of  mishaps  followed  drawing  the  sutures  too 
tightly,  which,  if  done,  leads  to  death  of  the  applied  edges  and  of 
course  to  failure.  They  must  be  drawn  only  sufficiently  close  to  bring 
the  surfaces  fairly  in  contact ;  the  subsequent  swelling  from  obstructed 
circulation  will  hold  the  surfaces  firmly  together  until  glued  to  each  other 
by  the  rapidly  forming  adhesive  material."^  With  regard  to  the  best 
way  of  disposing  of  the  divided  mesentery  after  removal  of  some  length 
of  intestine,  Dr.  Parkes  does  not  seem  to  be  decided.  It  would  seem 
from  his  account,  which  is  not  clear  on  this  point,  that,  after  tying  the 
mesenteric  vessels  (Fig.  Ill)  and  suturing  the  divided  ends  of  the  in- 
testine, the  cut  mesentery  should  be  united  to  the  now  joined  intestine, 
making  as  nearly  as  possible  a  continuous  surface  of  mesentery. 

I  quote  the  following  as  instances  of  what  injuries  the  surgeon  may 
expect  to  have  to  deal  with.  Bullet  wound  near  umbilicus;  seven 
openings  in  alimentary  canal — viz.,  three  openings  close  together  in 

*  The  sutures  were  of  No.  1  catgut  or  No.  2  silk ;  fully  curved  round  needles  are 
recommended,  or,  preferably,  ordinary  straight  sewing-needles.  The  method  used  was 
the  continuous  or  Lambert's  (Figs.  106,  107).  Great  stress  is  laid  on  not  allowing  the 
needle  to  enter  the  cavity  of  the  intestine,  a  point  of  which  the  importance  has  been 
shown  by  Mr.  Howse  in  gastrostomy. 


676  OPERATIONS  ON  THE  ABDOMEN. 

the  small  intestine  (31  feet  below  the  duodenum),  two  openings  in  the 
descending  colon,  and  two  in  the  rectum  ;  no  great  extravasation  ;  also 
a  large  vein  wound  in  the  mesentery  ;  death  from  peritonitis ;  bullet 
found  near  ischial  spine  (Annandale,  Lancet^  April  15,  1885).    Pistol 
wound   near  navel ;  seventeen  hours  later,  operation ;    two  pints  of 
bloody  serum  let  out,  with  small  clots,  but  no  fteces ;  seven  penetrating 
wounds  of  intestine,  six  in  the  small,  one  in  the  sigmoid  containing 
the  bullet;   all  the  oi^enings   plugged  with  ragged,  everted   mucous 
membrane ;  no  fecal  escape  till  edges  were  separated ;  careful  suturing 
and  toilet;  recovery  after  a  very  critical  condition  for  a  week  (Bull. 
New  York  Med.  Conn.,  February  14,  1885 ;  Ann.  of  Surg.,  May,  1885). 
Bullet  wound  (five  other  superficial  ones  in  hands,  etc.),  in  right  iliac 
fossa;  no  injury  to  intestine  by  bullet,  which  had  lodged  near  spine; 
while  it  is  clear    that  the    peritoneal  cavity  was  entered,  the  exact 
nature  of  the  abdominal  injury  is  not  very  clear;  the  case,  however, 
reflects  the  greatest  credit  on  the  operator,  who  had  to  meet  it  almost 
single-handed,  and  without  preparation  (Skelly,  Ann.  of  Surg.,  July, 
1887).     Bullet  entered  through  border  of  cartilages  of  ribs  to  left  of 
umbilicus,  passing  out  at  the  back  at  a  point  nearly  opposite ;  opera- 
tion fifteen  hours  later ;  much  bloody  serum  sponged  out,  but  no  clots, 
and  nothing  like  contents  of  stomach  or  intestine;  left  lobe  of  liver 
just  incised ;  no  wound  found  in  stomach,  which  was  slightly  distended ; 
six  days  later  all  abdominal  symptoms  had  subsided  (Andrews,  Journ. 
Amer.  Med.  Assoc,  August  15,  1885 ;  Ann.  of  Surg.,  November,  1885). 
Bullet  entrance  close  to  navel ;  operation  two  hours  later ;  abdominal 
cavity  full  of  blood ;   spirting  artery  in  mesentery ;   eleven  wounds 
requiring  suture  in  small  intestine,  and  two  in  ascending  colon ;  no 
fecal  extravasation,  but  a  melon-seed  body  found  and  removed ;  on  the 
thirteenth  day  great  rectal  tenesmus  led  to  discovery  of  blood  effusion 
in  pelvis;  three  pints  let  out  by  incision  about  2  inches  within  anus; 
recovery ;  bullet  passed  per  anum  (Hamilton,  Journ.  Amer.  Med.  Assoc, 
August  22,  1885;  Ann.  of  Surg.,  November,  1885).     Bullet  entrance  3^ 
inches  above  umbilicus,  and  just  to  left  of  middle  line ;    operation 
within  twenty-four  hours ;  rent  in  omentum  close  to  great  curvature 
of  stomach,  and  two  linear  rents  in  this  viscus  found  with  much  diffi- 
culty ;  operation  had  to  be  concluded  quickly  from  patient's  critical 
condition ;   death  witliin  a  few  hours  witli    acute  peritonitis ;   four 
wounds  found  in  upper  part  of  jejunum,  all  within  a  distance  of  3 
inches  (Briddon,  New  York  Surg.  Soc,  December  8, 1886 ;  Ann.  of  Surg., 
April,  1887).     Bullet  wound  2  inches  above  and  2  inches  inside  right 
anterior  superior  spine ;  operation  in  nine  hours ;  wound  found  in 
ascending   colon    pouring   out  faeces;    another  wound  in  colon  also 
pouring  out  faces;    both  sutured;  recovery  (McGraw,  Chicago  Med. 
Journ.  and  Exam.,  July,  1887;  Ann.  of  Surg.,  December,  1887).   Bullet 


GASTROSTOMY.  677 

wound  above  right  anterior  superior  spine;  operation  six  hours  after; 
large  loop  of  ileum  protruding,  with  several  openings  from  which  faeces 
were  oozing;  resection;  wound  enlarged,  and  several  small  shot  and 
some  wadding  removed ;  wound  not  closed ;  three  drainage-tubes ;  ftecal 
fistula;  ultimate  complete  recovery  (Freyer,  Deuts.  Med.  Woch.,  No.  28, 
July  15,  1886;  Ann.  of  Surg.,  October,  1886).  Bullet  wound  at  level  of 
top  of  ensiform  cartilage  to  riglit  side  of  middle  line,  over  border  of 
costal  cartilage ;  operation  three  hours  and  a  half  after ;  bruise  of  liver 
and  slight  tearing  of  omentum ;  clots  of  blood,  bullet,  and  wads  re- 
moved from  latter ;  recovery.  Two  bullet  wounds,  the  one  of  entrance 
84  inches  internal  to  right  anterior  superior  spine,  the  one  of  exit  3 
inches  behind  this  point ;  double  perforation  of  ileum,  3  feet  above 
ceecum ;  much  blood,  no  foeces,  gas  in  abdomen ;  resection  of  intestine ; 
death  on  sixth  day  with  moderate  peritonitis  and  pneumonia  (Barker, 
Brit.  Med.  Journ.,  March  17,  1888).  A  helpful  table  will  be  found  in 
this  paper,  and  one  by  Sir  W.  MacCormac,  ibid.,  May  11,  1887. 


CHAPTER  VII. 
OPERATIONS  ON    THE  STOMACH. 

GASTROSTOMY.  —  GASTROTOMY.  —  DIGITAL  DILATA- 
TION OF  PYLORUS.— EXCISION  OF  PYLORUS.— 
CURETTING  CANCER  OF  STOMACH.— GASTROEN- 
TEROSTOMY. —  DUODENOSTOMY.  —  JEJUNOSTOMY. 

GASTROSTOMY. 

This  is   one   of  those   operations  which,  after  being  called   into 
temporarily  marked  vitality,  are  just  now  allowed  to  languish. 
Indications. 

1.  Cancerous  stricture.  This  also  includes  invasion  of  the  oesopha- 
gus, secondarily,  from  primary  cancer  of  the  mediastinal  glands,  etc. 

2.  Cicatricial  stricture,  whether  traumatic  or  syphilitic. 

3.  Cancerous  disease  of  the  pharynx. 

The  first  of  these,  from  its  frequency,  requires  separate  notice. 

1.  Cancerous  Stricture.  —  Here  several  points  call  for  attention. 
Amongst  the  chief  are — the  question  of  the  treatment  of  oesophageal 
cancer  by  passage  of  tubes  or  gastrostomy ;  the  mortality  of  the  latter 
operation  ;  the  best  date  for  performing  it. 

Between  treatment  by  gastrostomy  and  that  by  tubes  no  fair 
comparison  can  be  made,  because  the  former  operation  has,  in  such 
a  large  number  of  cases,  been  performed  under  most  unfavorable 


678  OPERATIONS  ON  THE  ABDOMEN. 

conditions.  Much  too  often  it  has  been  put  off  till  the  patient, 
scarcely  able  to  swallow  liquids,  is  just  kept  alive  by  enemata.  Such 
patients,  worn  out  by  the  miseries  of  slow  starvation,  often  with  sec- 
ondary disease  and  lung  and  pleural  trouble,  are  not  in  a  condition  to 
be  submitted  to  abdominal  section,  and  are  not  likely  to  respond  to 
the  call  made  upon  their  vitality  to  unite  two  serous  surfaces  firmly 
together,  on  which  depends  the  success  of  the  operation.  I  do  not 
think  that  I  exaggerate  if  I  say  that,  in  a  distinct  proportion  of  the 
cases  in  which  the  surgeon  is  asked  to  perform  gastrostomy,  the  hand 
of  death  is  already  on  the  patient,  and  something  next  door  to  the 
decomposition  of  the  grave  has  already  set  in. 

In  advising  gastrostomy  each  case  must  be  decided  on  its  merits; 
the  patients  here  are  not  only  adults,  but  well  on  in  life,  and,  when 
assured  that  the  end  is  certain,  the  surgeon  may,  in  most  cases, 
having  put  all  the  risks  before  the  patient,  leave  it  to  him  to  decide. 
But  I  think  that  if  the  patient,  having  previously  declined  it,  only 
asks  for  operation  when  it  is  clearly  too  late,  the  surgeon  should 
be  firm  enough  to  decline  to  operate  where,  on  every  ground,  his 
interference  will  be  hopeless. 

The  following  points  help  in  a  decision  between  gastrostomy  and 
tubage : 

i.  Food  taken. — As  long  as  pulpy,  semi-solid,  or  even  a  proportion 
of  solid  food  is  taken,  tubage  should  be  persevered  with.  But  when 
the  time  comes  that  the  patient  is  becoming  restricted  to  liquids,  the 
hour  for  a  successful  gastrostomy  is  slipping  by.  When  the  patient 
is  fed  by  enemata  only,  and  merely  takes  ice  by  the  mouth,  it  is  too 
late  to  operate. 

ii.  Amount  of  pain  felt  with  and  difficulty  in  passing  bougies  or 
tubes. — This  will  vary  a  good  deal  with  different  cases.  When,  from 
the  increased  expectoration,  dyspnoea,  paroxysmal  cough,  foetor  of 
sputum  or  bougie,  it  is  evident  that  the  passage  of  instruments  causes 
increased  ulceration  and  sloughing,  when  this  is  increasingly  accom- 
panied with  pain  and  evidence  of  laryngeal  irritation,  gastrostomy 
should  be  proposed. 

iii.  Site  of  stricture. — The  lower  down  this  is,  the  more  difficulty 
will  there  usually  be  in  dealing  with  it  by  dilatation,  and  the  nearer 
are  important  parts. 

iv.  Condition  of  patient. — Here  the  rate  of  emaciation  must  be 
watched — anything  like  a  loss  of  1  to  2  lbs.  a  week  is  very  ominous. 
How  far  is  the  strength  preserved?  how  far  does  the  patient  tend  to 
give  up  his  life-habits?  how  far  is  he  bedridden?  Where  the  pulse 
is  thready,  the  extremities  cold,  the  temi^erature  never  up  to  normal, 
the  case  has  gone  too  far. 

V.  Condition  of  viscera. — Evidence  of  implication   of  trachea  or 


GASTROSTOMY.  679 

bronchi,  of  pleuritic  effusion,  and  of  broncho-pneumonia  must   be 
sought  for. 

I  would  thus  sum  up  this  question  of  gastrostomy  or  treatment  by 
tubes :  As  long  as  a  patient  can  swallow  solids  or  semi-solids,  treat- 
ment by  tubes  and  bougies  should  be  persevered  with.  Whenever 
they  can  be  introduced,  the  tubes  ingeniously  devised  by  Mr.  Sy- 
monds*  will  be  preferred.  These  have  a  funnel-shaped  extremity 
resting  on  the  upper  end  of  the  stricture,  are  introduced  by  a  conical 
bougie,  and  are  kej^t  in  situ  by  a  loop  of  silk,  which  comes  out  of  the 
mouth  and  is  looped  round  the  ear.  They  are  not  unsightly,  have 
the  great  advantage  of  allowing  the  patient  to  swallow  his  saliva  and 
food,  and  thus  retain  the  pleasures  of  taste. 

If  a  larger  pattern  of  bougie  is  needed,  none  is  more  suitable  than 
the  flattened  bulbous  one,  ending  in  a  conical  point,  of  "Sir.  Durham.f 

Any  surgeon  treating  cancerous  stricture  here  by  dilatation  must 
remember  that  treatment  of  cancer  in  this  way  is  contrary  to  what  is 
generally  practiced,  and  is  only  justifiable  here  on  special  grounds — e.g., 
the  fatality  of  the  disease  and  the  risks  of  gastrostomy  ;  that  these  risks 
have  been  enormously  increased  by  the  way  in  which  this  operation 
has  been  deferred  ;  that  there  comes  a  time  in  these  cases  when  tubes, 
both  short  and  long,  can  no  longer  be  made  use  of;  and  that  if  gas- 
trostomy has  been  deferred  till  now  it  had  better  not  be  performed  at 
all.  In  other  words,  the  patient  should  understand  that  if  he  shuns 
the  risks  of  an  early  operation  he  renders  himself  liable  to  other  but 
as  serious  risks  b}^  deferring  it  till  an  hour  when  he  can  onh^  ask  for 
it,  and  the  surgeon  only  attempt  it,  as  an  almost  utterly  forlorn  hope. 

The  question  of  which  gives  the  greatest  comfort  cannot  be  an- 
swered dogmatically.  But  no  one  who  has  seen  many  cases  of 
gastrostomy,  and  met  with  a  fair  proportion  of  success,  will  hesitate 
to  prefer  the  result  of  this,  if  performed  early,  with  its  gain  of  weight^ 
and  freedom  from  pain  and  irritation,  to  the  passage  of  tubes  neces- 
sarily more  and  more  frequent  and  difficult  as  the  case  progresses, 
with  the  not  infrequent  distress  and  choking  when  they  are  intro- 
duced, the  blockage  of  the  hollow  one  by  septum  or  food,  and  the 
withdraAval  and  re-introduction,  easily  effected,  no  doubt,  for  some 
time,  but  ever  irritating  and  fretting  the  growth. 

*  Clin  ioc.  Trans.,  vol.  xviii.  p.  155.  It  is  clear  from  this  case  that  patients  can  be 
kept  alive  as  long  by  tiibage  as  by  gastrostomy,  and  that  in  some  cases  even  a  malig- 
nant stricture  can  be  dilated.  On  the  other  hand,  the  passage  of  tubes,  where  there 
is  considerable  narrowing,  clearly  requires  some  force,  and  thus  needs  skilled  and 
very  careful  hands.  Furthermore,  the  blocking  of  the  tubes  in  the  later  stages  will 
necessitate  frequent  changing.     The  tubes  are  made  by  Messrs.  Downs. 

t  Syst.  of  Surg.,  vol.  i.  p.  798.     The  bougies  are  made  by  Kroline  and  Hawksley. 

X  Mr.  Symonds'  case  {loc.  supra  cit.)  gained  at  first  1  st.  9  lbs.,  and  tould,  with  the 
tube  in,  drink  a  pint  of  milk  at  a  draught. 


680  OPERATIONS  ON  THE  ABDOMEN. 

T  have  performed  gastrostomy  seven  times,  in  each  case  for  cancer 
of  the  oesophagus :  in  three  i3atients  the  operation  was  asked  for  too 
Lite  ;  in  one,  my  seventh  case,  the  patient  died  from  an  accident,  for 
which  I  am  responsible ;  the  other  three  recovered  well.  One,  a  young 
married  woman,  had  had  symptoms  six  months ;  she  was  in  the  fourth 
month  of  pregnancy  when  operated  on ;  she  lived  in  comfort  for  six 
months,  and  died,  a  month  after  giving  birth  to  a  child  at  the  full  time, 
of  extension  to  the  lung.  Another  patient  lived  between  three  and  four 
months,  and  would  have  survived  longer  if  it  had  not  been  for  his  care- 
lessness as  to  exposure.  A  third  was  alive  and  progressing  satisfac- 
torily when  last  heard  of  four  months  after  the  operation. 

Operation  (Fig.  112).— Method  of  Howse*  by  Two  Stages. 

Fird  SUige. — Those  precautions  being  taken  against  shock,  such  as 
warm  wraps,  hot  bottles,  ether  as  an  antesthetic  if  the  condition  of  the 
lungs  admits  of  it,  and  if  it  is  quietly  taken  without  troublesome, 
heaving  breathing,  the  surgeon  will  usually  find  it  most  convenient  to 
stand  on  the  right  side  and  to  have  his  patient  drawn  over  to  this  side 
of  the  table.  The  outline  of  the  stomach  should  be  percussed  out  first, 
and  the  shoulders  somewhat  raised  and  the  hips  slightly  flexed,  to 
relax  as  much  as  possible  the  tension  of  the  soft  parts,  which  often 
here  fall  with  harassing  sharpness  over  the  epigastric  angle  from  the 
prominent  ribs  down  to  the  wasted,  retracted  umbilical  region. 

Mr.  Howse  {Diet.  Prad.  Surg.,  p.  590)  recommends  the  following 
incision  :  (1)  An  oblique  one,  about  2J  inches  long,  parallel  with  and 
about  1  inch  below  the  lower  margin  of  the  left  costal  cartilages.  This 
incision  should  start  about  H  inch  from  the  middle  line,  and  its  length 
must  depend  on  the  varying  development  of  the  rectus  muscle.  It 
should  not  go  higher  than  the  above  point,  as  it  will  not  leave  enough 
free  skin  and  muscle  between  the  cartilages  and  the  incision  to  fasten 
the  sutures  to.  This  first  incision  is  only  to  be  carried  through  the 
skin  and  fascia.  When  made,  the  sheath  of  the  rectus  will  be  seen  at 
the  inner  end,  and  at  its  outer  end  a  portion  of  the  linea  semilunaris 
and  of  the  external  oblique.  The  usual  plan  of  continuing  the  opera- 
tion is  to  have  the  muscles  and  fascise  of  the  abdomen  incised  in  the 
same  way  as  the  superficial  parts.  Mr.  Howse  prefers  to  continue  the 
operation  as  follows :  (2)  The  lips  of  the  wound  being  separated 
towards  the  inner  part  as  widely  as  possible  by  retractors,  a  vertical 
incision  is  made  in  the  sheath  of  the  rectus  a  little  from  its  outer 
margin.     The  vertical  fibres  of  this  muscle  will  then  be  seen,  and  these 

*  Mr.  Greig  Smith  (Abdom.  Surcf.,  p.  302)  states  that  the  plan  of  operating  in  two 
stages  was  originally  suggested  by  Egebert,  a  Norwegian  surgeon  (1841),  and  also 
advised  by  Nfelaton.  It  is  to  Mr.  Howse's  practice,  however,  tiiat  we  owe  our  knowl- 
edge that  this  operation  is  safe  if  performed  in  two  stages,  with  strict  antiseptic  pre- 
cautions, and  when  not  too  Jong  deferred. 


GASTROST(JMY.  681 

should  be  separated,  not  cut,  with  the  handle  of  the  scalpel,  and  the 
posterior  part  of  the  sheath  exposed.  This  may  then  be  incised  ver- 
tically. 

From  my  experience  of  seven  cases  I  prefer,  as  simpler,  a  single 
vertical  incision  (Fig.  112)  beginning  opposite  to  the  end  of  the  eighth 
intercostal  space  and  passing  down  for  3  inches  over  the  rectus — i.  e., 
about  2  inches  from  the  linea  alba.  The  fibres  of  the  rectus,  being 
exposed,  are  torn  straight  through  with  a  steel  director,  and  the 
posterior,  somewhat  concave  layer  of  its  sheath  exposed.  This  is 
carefully  divided  for  the  full  length  of  the  incision,  and  the  extra- 
peritoneal fat  (if  present)  and  the 

peritoneum  picked  up  and  opened  Fi<^^-  ^^2. 

together.      A   finger  is   now   intro-  ^^.  ^''^**^   '"  * 

duced    (Fig.    112)    to   feel   for    the  '  W'"( 

stomach,*  and  I  think  it  well  now        . ^  ^\\ 

to  cover  the  wound  over  with  car- 

bqlized  lint  and  to  stop  the  spray,      ^ 

as  this  avoids  chilling  the  patient         ""AtouVn^^  jaV,  % 

and  also  prevents  any  spray  run-.  ,   If^^'/ 

ning  into  the  peritoneal  cavity.  -_  ^      ,   ^^  / 


As  a  rule,  the  contracted  stomach        ^^^^;,>^        .  n^ ^^j^^^j^^^^^w^^^^^^^^^^^^l 
lies  high  up  under  the  left  lobe  of 

,  1       T  T  .         i     1       1        1      1  The  finger  searching  for  the  stomach 

the  liver,  and  requires  to  be  hooked  ^^^^^^^  ^  ^^.^i^^i  ^^^^^^^^^ 

downwards  and  forwards  into  the 

wound.  Not  unfrequently  the  great  omentum  presents  first,  and  it  is 
easy,  by  seeking  too  low  down,  to  draw  up  the  colon.  In  case  of 
difficulty  the  best  plan  is  to  find  the  anterior  border  of  the  liver,  trace 
up  the  under  surface  to  the  portal  fissure,  and  thence  along  the  lesser 
omentum  to  the  stomach.  This  is  told  by  its  thicker,  more  substaiitial 
feel  and  pink-red  color. 

The  stomach  being  drawn  up,  a  part  is  chosen  on  its  anterior  sur- 
face, free  from  vessels,  and  as  near  as  possible  to  the  cardiac  end. 

The  stomach  is  next  fixed  to  the  edges  of  the  wound  with  sutures 
of  carbolized  silk  and  wire.  Mr.  Howse  thus  ties  his  chief  sutures 
over  bits  of  bougie  :  "  Drawing  the  stomach  well  over  to  one  side,  a 
needle  (in  handle)  carrying  the  silk  should  be  passed  through  the 
serous  and  muscular  coats  of  the  stomach  only,  and  should  then 
transfix  the  abdominal  parietes  about  1  inch  from  the  wound.  The 
needle  is  now  withdrawn,  leaving  one  end  of  the  silk  on  the  surface, 
and,  without  unthreading  the  other  end,  the  abdominal  parietes  are 
again  punctured  alone.  The  needle  is  now  unthreaded  and  withdrawn. 
The  two  ends  of  silk  will  thus  be  left  projecting  from  two  distinct 

*  While  the  finger  feels  for  the  stomach,  it  also  examines  for  any  enlarged  glands. 


682  OPERATIONS  ON  THE  ABDOMEN. 

wounds  on  the  skin,  close  by  one  another,  and  holding  up  a  bit  of  the 
serous  and  muscular  coats  of  the  stomach.  Before  tying  any  one 
suture  it  is  best  to  introduce  the  others,  drawing  the  stomach  well 
over  from  the  side  towards  which  it  is  wished  to  introduce  the  suture. 
Six  or  eight  sutures  introduced  in  this  fashion  are  usually  used.  The 
result  is  to  fix  the  gastric  peritoneum  in  a  circle  about  1  inch  round 
the  wound.  The  part  of  the  stomach  exposed  in  the  wound  should 
then  be  fixed  to  the  lips  of  the  incision  by  small  wire  sutures,  intro- 
duced by  a  small  curved  needle  held  in  a  needle-holder,  these  again 
only  taking  up  the  serous  and  muscular  coats  of  the  stomach." 

Other  surgeons  have  dispensed  with  the  above,  using  sutures  in  the 
ordinary  way.  By  some,  hare-lip  pins  have  been  used.  Others,  to 
ensure  apposition  of  the  jDeritoneal  surfaces,  have  first  sutured  the 
parietal  peritoneum  to  the  edges  of  the  wound. 

The  additional  time  spent  in  careful  stitching  will  well  repay  the 
operator.  However  the  sutures  are  inserted,  the  following  points,  on 
which  Mr.  Hovvse  in  introducing  his  operation  laid  much  stress,  should 
be  carefully  attended  to :  (a)  To  make  the  needle  travel  for  a  suffi- 
cient distance  in  the  muscular  coat  in  taking  up  the  stomach.  (/9) 
Not  to  include  or  puncture  the  mucous  coat,  for  fear  of  causing  septic 
fistulse.  (y)  To  bring  the  needle  through  the  parietes  quite  an  inch 
from  the  edges  of  the  wound,  (d)  In  doing  so,  to  include  the  jmrietal 
peritoneum,  (e)  To  bring  up  a  circle  of  stomach  a  full  inch  in 
diameter. 

When  the  stomach  is  secured — and  the  sooner  it  is  to  be  ojiened,  the 
more  carefully  must  the  stitching  be  carried  out — a  suggestion,  I 
believe,  of  Mr.  Bryant's  should  be  followed,  and  one  or  two  fine 
sutures  of  silk  or  catgut  introduced  in  the  centre  to  guide  the  surgeon, 
in  a  few  days,  to  a  safe  site  of  puncture  (vide  infra).  The  upper  and 
lower  angles  of  the  wound  are  next  closed,  if  gaping. 

Free  as  the  wound  has  seemed  before,  it  is  now  markedly  puckered 
up.  A  little  iodoform  is  dusted  on,  a  piece  of  protective  smeared  with 
carbolic  oil  applied,  and  then  dry  gauze  dressings  and  salicylic  wool, 
with  a  many-tailed  bandage. 

When  in  bed  the  position  of  the  patient  must  be  such  as  to  relax  the 
parts.  A  little  mor})hia  should  be  given  subcutaneously,  whenever 
not  contra-indicated ;  great  attention  paid  to  keeping  the  patient 
warm,  and  nutrient  enemata,  followed  by  one  of  Burroughs  and 
Wellcome's  nutrient  suppositories,  given  every  three,  four,  or  six 
hours.* 

Second  Stage. — This  in  all  cases  admitting  of  delay  should  be  deferred 
till  the  third,  fourth,  or  fifthf  day,  so  as  to  give  time  for  firm  adhesions 

*  Thirst  may  be  relieved  by  glycerine  and  iced  water  as  a  naouth  and  throat  wash. 
f  Mr.  Howse  has  usually  adopted  this  date. 


GA8TEOSTOMY.  683 

to  form  between  the  two  surfaces,  and  thus  to  soundh'-  shut  off  the 
general  peritoneal  cavity.  No  previous  change  of  dressing  will  proba- 
bly have  been  required.  The  wound  is  now  found  still  more  puckered, 
its  edges  inverted  somewhat,  and  almost  in  apposition  save  for  the 
strips  of  gauze  which  have  been  inserted.  The  stomach  surface  is  no 
longer  recognizable  as  such,  being  coated  with  lymph,  this  showing 
the  importance  of  the  guiding  sutures.  Between  these,  or  close  to  a 
loop  if  single,  the  stomach  wall  is  punctured  by  a  quick  stab  with  a 
very  sharp  tenotom}^  knife,  the  wall  being  raised  and  steadied  by  the 
loop.  A  piece  of  No.  7  gum-elastic  catheter  is  then  slipped  in  as  the 
knife  is  withdrawn.*  To  the  end  of  the  catheter  a  bit  of  tubing  and 
a  small  funnel  having  been  attached,  a  few  drachms  of  milk  and 
brandy  are  thus  quickly  giyen.  The  tube  is  then  tied  with  silk  or 
plugged,  and  left  projecting  amongst  some  strips  of  dry  gauze  which 
cover  the  wound.  The  spray  is  used  for  the  first  few  dressings,  and  a 
little  iodoform  dusted  on  after  each.  A  larger  tube  is  soon  introduced, 
and  an  india-rubber  tracheotomy  tube  is  sometimes  found  convenient 
till  the  fistula  is  soundly  formed. 

For  the  first  few  days  milk  and  brandy,  just  warmed,  and  peptonized 
if  preferred,  should  be  the  chief  food  given  with  the  yolks  of  one  or  two 
eggs.  A  little  later  beef-tea,  soups,  well-pulped  vegetables,  with  plenty 
of  fluid,  should  be  given.  In  Mr.  Howse's  words,  "  When  the  larger 
sizes  of  tubes  have  been  introduced,  solid  food  may  be  poured  into  the 
stomach  by  the  aid  of  a  large  wide-mouthed  sj'ringe.  This  food  should 
be  minced  meat,  with  a  certain  proportion  of  vegetables,  all  finely 
ground  in  the  mincing  machine." 

Patients  are  often  very  ingenious  in  feeding  themselves.  Some,  to 
enjoy  the  taste  of  food,  have  masticated  solids  and  then  passed  them 
through  the  fistula.f 

If  the  operation  has  been  deferred  till  too  late,  and  it  is  absolutely 
needful  to  feed  the  patient  at  once,  the  safest  method  will  probably  be 
to  introduce,  every  few  hours,  a  small  amount  of  liquid  through  one 

*  This  sounds  simple  enough,  but  it  is  by  no  means  always  easy  to  feel  certain  that 
the  stomach  has  been  ojjened.  Tiiis  is  due  to  the  puckered  contraction  of  the  wound 
and  alteration  of  its  surface,  the  stomach  coat  being  thus  no  longer  recognizable,  to  its 
lying  much  deeper  than  would  be  expected,  making  "  the  operator  sometimes  fear  that 
he  has  punctured  the  lesser  bagof  the  peritoneum  ''  (Howse).  In  one  case,  my  seventh, 
though  I  thought  I  had  punctured  the  stomach  directly  and  sufBciently,  it  was  not  so. 
The  patient  dying  two  days  after,  peritonitis  and  fluid  food  in  the  abdominal  cavity 
were  found.  The  puncture  and  catheter  had  both  run  obliquely  through  the  stomach 
wall,  and  communicated  with  the  cavity  of  this  viscus  and  that  of  the  peritoneum  as 
well. 

t  Thus,  Mr.  Durham  (Syst.  of  Surg.,  vol.  i.  p.  803  ;  Lond.  Med.  Bee,  March,  1878) 
mentions  a  patient  of  Trendelenbiu'g  who,  after  masticating  his  food,  spat  it  into  a 
funnel,  and  then  forced  it  on  tiirough  a  tube  into  his  stomach. 


684  OPERATIONS   ON   THE   ABDOMEN. 

of  the  large  hypodermic  syringes  made  for  exploration,  and  holding 
a  drachm  or  two.  The  puncture  must  be  repeated  at  each  occasion  of 
feeding.  In  these  cases  especial  care  must  be  taken  to  the  suturing  the 
stomach,  and,  if  this  is  opened  at  once  and  a  tube  introduced,  every 
precaution  must  be  taken  to  go  through  the  mucous  membrane,  and 
not  to  detach  this  or  to  loosen  the  sutui'es.  If  a  catheter  or  tube  is 
introduced  at  once,  it  must  be  a  fine  one,  otherwise  escape  of  secretions 
will  render  the  wound  aseptic,  and  the  result  a  fatal  one. 

Diflaculties  in  and  after  Grastrostomy. 

i.  The  very  prominent  angle  formed  between  the  ribs  and  the  sunken 
umbilical  region  (p.  680). 

ii.  Haemorrhage.  This  will  be  almost  nil  if  the  rectus  fibres  are 
separated  with  a  director,  and  the  veins  on  the  stomach  carefully 
avoided. 

iii.  Finding  the  stomach.  • 

iv.  Drawing  this  up  into  the  wound  if  itself  affected  by  disease,  as 
when  the  primary  disease  is  situated  very  low  down  in  the  oesophagus, 
or  if  it  is  adherent  by  reason  of  secondary  deposits. 

v.  Completing  the  second  stage  of  the  operation. 

vi.  Intense  pain  on  introducing  food  into  the  stomach.  In  a  patient 
of  ]\Ir.  Butlin's  {Brit.  Med.  Journ.,  April  14,  1883)  this  was  found  to  be 
the  case,  the  patient  dying  nearly  a  month  after  the  operation.  Mr. 
Butlin  attributes  this  pain  to  his  opening  having  been  close  to  the 
pylorus.'!^  If  it  is  thought  that  the  opening  is  made  too  near  either 
extremity  of  the  stomach,  it  would  be  well  after  feeding  to  keep  the 
patient  turned  on  to  the  opposite  side. 

vii.  Leakage  of  gastric  juice  and  regurgitation  of  food.  This  is  an 
extremely  troublesome  complication,  leading,  as  it  does,  to  most  rebel- 
lious eczema  and  erysipelas.  It  is  best  prevented  b}^  making  as  small 
a  wound  as  possible  in  the  abdominal  walls,  going  through  the  rectus 
muscle,  and  opening  the  stomach  by  a  mere  puncture.  If,  in  spite  of 
these  precautions,  leakage  still  takes  place,  leaving  out  the  tube  for  a 
few  hours  at  a  time  will  allow  of  some  recontraction.  The  patient 
should  also  be  kept  as  flat  as  possible  after  feeding.  Regurgitation  of 
food  is  often  due  to  the  stomach  being  opened  too  near  to  tlie  pylorus. 

In  some  cases  of  gastrostomy  for  non-malignant  stricture  the  fistula 
has  been  subsequently  closed.  I  did  this  in  1877,  at  Mr.  Howes's 
request,  in  a  most  successful  case  of  gastrostomy  of  his  for  cesophageal 
stenosis  after  swallowing  a  corrosive  poison.  Mr.  Davies-Colley  has 
published  another  equally  favorable  ending  in  a  case  in  Avhich  the 

*  Thus  causing  constant  dragging  on  a  fixed  part.  The  middle,  or  cardiac  end  of 
the  stomach  should  be  opened,  as  being  more  movable  and  less  likely  to  lead  to  rapid 
escape  of  the  food. 


GASTROTOMY.  685 

cesophageal  mischief  had  been  S3'philitic  (Guy^s  Hosp.  Reports,  1884, 
vol.  xxvii.  p.  367). 
Causes  of  Death  after  Gastrostomy. 

1.  Inanition  and  exhaustion,  the  operation  being  performed  too  late. 

2.  Peritonitis. 

3.  Extension  of  the  disease  to  surrounding  parts — e.g.,  trachea, 
bronchi,  etc. 

4.  Lung  affections. 

5.  Haemorrhage. 

6.  Acute  gastritis. 

GASTROTOMY.* 

Indications. — These  are  very  few,  the  majority  of  bodies  swallowed 
passing  through  the  pylorus.  Of  the  few  which  will  call  for  operations, 
forks,  as  in  MM.  Labbe's  and  Pean's  cases,  and  masses  of  hair,  as  in 
Mr.  K.  Thornton'sf  patient,  are  good  instances.  Increasing  pain, 
vomiting,  emaciation,  and  sufficient  time  having  elapsed  to  allow  of 
the  body  passing  will  be  the  chief  justifications  of  an  operation. 

Operation. — Such  cases  as  Mr.  Thornton's  show  that  this  oper- 
ation can  be  safely  performed  at  one  stage. J 

The  parts  being  cleansed  and  the  abdomen  relaxed,  one  of  the  fol- 
lowing incisions  is  made :  (1)  Over  the  body  itself,  when  this  can  be 
felt.  (2)  In  the  case  of  a  large  bod}^  in  the  middle  line,  from  the 
xiphoid  cartilage  down  to  or  below  the  umbilicus.  (3)  One  of  the  in- 
cisions given  for  gastrostomy — e.g.,  one  parallel  with  the  left  costal 
margin  and  about  an  inch  below  it,  reaching  from  a  point  near  the 
xiphoid  cartilage  obliquely  downwards  and  outwards  to  a  point  oppo- 
site to  the  ninth  rib.  One  of  the  first  two  will  probably  be  the  best. 
The  abdominal  wall  being  divided,  and  the  peritoneum  opened  as  in 
gastrostomy  (p.  681),  the  exact  site  of  the  foreign  body  is  made  out. 
If  this  be  pointed,  great  care  must  be  taken  not  to  let  it  damage  the 
stomach  during  the  needful  manipulations.  In  such  cases  the  exter- 
nal opening  must  be  free,  that  the  surgeon  may  see  what  he  is  about. 
In  the  case  of  such  a  body  as  a  fork  the  blunt  end  must  first  be  found. 

*  By  this  term  is  meant  an  incision  into  the  stomach  for  the  removal  of  foreign 
bodies,  the  opening  being  immediately  afterwards  closed,  as  opposed  to  "  gastrostomj-," 
the  making  of  a  more  or  less  permanent  fistulous  opening. 

t  Lancet,  January  9,  1886. 

X  It  has  been  proposed  by  some  to  facilitate  finding  the  stomach  by  distending  this 
with  eflervescing  media,  but,  as  Mr.  Greig  Smith  points  out,  the  disadvantages  are  se- 
rious— viz  ,  trouble  to  the  patient,  liability  of  the  distending  medium  to  escape  into  the 
peritoneal  cavity,  and,  lastly,  the  increased  difficulty  of  finding  the  body  in  a  distended 
stomach.  In  Mr.  Thornton's  case,  the  hair,  weighing  2  lbs.,  greatly  distended  the 
stomach.  It  would  probably  be  well,  in  the  case  of  a  smaller  body,  to  wash  out  the 
stomach  beforehand  with  a  dilute  solution  of  boracic  or  salicylic  acid. 


G86  OPERATIONS  ON  THE  ABDOMEN. 

When  the  surgeon  has  decided  where  to  open  the  stomach,  he  brings 
this  part  out  of  the  wound  and  carefully  packs  sponges  all  around  it, 
so  as  to  steady  it,  and  also  to  shut  off  the  jjeritoneal  cavity. 

The  stomach  is  now  opened  by  an  incision  transverse  to  its  long 
axis,  and  of  length  adiipted  to  the  case.  As  far  as  possible  any  vessels 
must  be  avoided,*  but  any  that  spring  will  at  once  be  commanded  by 
SjDcncer  Wells'  forceps.  The  body  is  next  extracted  with  suitable  for- 
ceps or  a  scoop,  care  being  now  taken  not  to  damage  the  stomach, 
especially  if  the  foreign  body  has  set  up  inflammation  or  ulceration, 
and  to  allow  no  blood  or  mucus  to  escape  into  the  peritoneal  cavity .f 

Before  introducing  the  sutures,  Mr,  Thornton  placed  a  carbolized 
sponge  "  to  keep  the  edges  in  apposition  for  suture,  and  to  prevent 
accumulation  of  blood  in  the  organ.  Fifteen  sutures  of  fine  carbolized 
silk  were  then  introduced  through  all  the  coats,  the  needle  being 
slanted  through  the  wall  so  as  to  come  out  just  at  the  inner  edge  of  the 
mucous  membrane,  which  was  much  inclined  to  curl.  The  interrupted 
sutures  were  passed  so  as  to  control  the  cut  vessels,  and  no  ligatures 
were  used.  Another  row  of  similar  sutures  was  then  passed  between 
each  of  the  deep  sutures,  but  only  through  the  peritoneum.  The  deep 
sutures  entered  the  peritoneal  coat  about  i  inch  from  the  edge  of  the 
incision,  and  were  i  inch  apart;  the  superficial  sutures  were  entered 
about  the  same  distance  from  the  edge,  and  ran  along  just  under  the 
peritoneum.  When  these  were  all  in  place  the  sponge  was  removed 
from  the  stomach,  and  they  were  tied,  the  deep  first.  These  two  rows 
caused  some  inversion  of  the  peritoneum,  and  the  two  outer  and  upper 
edges  of  the  peritoneal  edges  of  the  depression  thus  formed  were 
brought  together  by  a  continuous  suture  of  very  fine  carbolized  silk. 
....  The  closed  wound  measured  exactly  3  inches." 

Stomach  feeding  was  only  commenced  forty-eight  hours  after  the 
operation,  a  teaspoonful  of  iced  water  and  milk  being  given  every  half- 
hour,  the  quantity  being  increased  till  the  afternoon  of  the  next  day, 
when  2  oz.  were  given  every  hour.  On  the  sixth  day  3  oz.  were  given 
every  two  hours.  On  the  fourteenth  day  com-flour  was  added  to  the 
diet,  on  the  fifteenth  some  crumbled  bread,  and  gradually  an  ordinary 
light  diet.  During  the  first  week  3  oz.  of  beef-tea  were  injected  into  the 
bowel  every  three  hours,  with  20  drops  of  laudanum  every  six  hours. 
The  patient  made  an  excellent  recovery,  though  Mr.  Thornton  had  to 
remove  a  sponge  from  tlie  abdomen  the  day  after  the  operation. 

*  Blunt-pointed  scissors  will  probabls'  be  most  convenient  here. 

t  Mr.  Greig  Smith  (loc.  supra  cit.)  writes  :  "  When  the  foreign  hoc) y  has  been  removed, 
it  may  be  wise,  if  there  is  much  mucoid,  purulent,  or  bloody  material  in  the  stomach, 
to  cleanse  it  by  means  of  small  sponges  on  holders.  The  less  the  stomach  is  irritated 
the  better,  however." 


DILATATION   OF   THE   PYLORUS.  687 

DIGITAL  DILATATION  OP  THE  ORIFICES  OF  THE 

STOMACH. 

We  owe  this  operation  to  Prof.  Loreta  *  of  Bologna,  whose  two  first 
cases  Mr.  Holmes  was,  I  believe,  the  first  to  bring  prominently  under 
the  notice  of  English  surgeons. 

DILATATION  OF  THE  PYLORUS. 

Indications.f — In  deciding  as  to  the  justifiabilit}'  of  the  operation, 
we  must  consider — (1)  the  diagnosis ;  (2)  the  failure  of  previous 
treatment. 

(1)  The  Diagnosis. — Cancer  and  idiopathic  gastritis  are  the  chief 
conditions  which  must  be  distinguished  from  simple  fibrous  stricture 
of  the  pylorus. 

(«)  Cancer. — This  may  be  excluded  by  the  long  course  of  the  symp- 
toms, the  delay  in  the  onset  of  cachexia  and  exhaustion,  and  b}^  the 
age|  of  the  patients. 

(/S)  Dilatation  due  to  Idiopathic  Gastritis. — Prof.  Loreta  points  out 
that  here  the  diagnosis  will  be  aided  by  attention  to  the  following : 
If  the  matters  rejected  or  extracted  from  the  stomach  in  the  two  dis- 
eases are  allowed  to  settle,  and  then  examined,  the  deepest  layer  of 
the  sediment  in  cases  of  obstruction  from  fibrous  stricture  will  be  found 
to  consist  of  acid  chyme  well  digested,  and  that  the  patients  here  have 
appetite  or  even  hunger  after  vomiting  ;  that,  on  the  contrary,  in  idio- 
pathic gastritis  the  deep  layer  of  the  vomit  contains  much  undigested 
detritus  and  but  little  chjaiie,  and  that  after  vomiting  there  is  indiflFer- 
ence  to  or  loathing  of  food.  Prof.  Loreta  explains  these  differences 
by  the  fact  that  in  the  mechanical  obstruction  the  coats  of  the  stomach 
are  more  likely  to  be  uninjured,  and  that  thus  gastric  digestion  still 
goes  on  and  the  peptones  are  still  absorbed. § 


*  Prof.  Loreta's  first  case  is  reported  in  the  Lancet,  August  18,  18S3.  The  ninth 
operation,  one  of  dilatation  of  the  cardiac  orifice,  is  briefly  given  in  the  same  journal, 
April  26, 1884.  Mr.  Holmes's  summary,  a  very  full  one,  of  two  papers  by  Prof.  Loreta 
will  be  found  in  the  Brit.  Med.  Journ.,  February  21,  1885.  Any  surgeon  about  to  per- 
form these  operations  should  refer  to  this.  Mr.  Haggard's  case — the  first  successful 
one  performed  by  an  English  surgeon — was  published  in  the  Brit.  Med.  Journ.,  Feb- 
ruary 19,  1887.  In  the  same  journal  for  March  17,  1888,  is  a  note  that  the  patient 
continues  perfectly  well. 

t  These  must  include  those  for  both  operations. 

X  Thus  in  six  of  the  cases  mentioned  in  Mr.  Holmes's  paper  the  ages  were  eighteen, 
twenty-four,  twenty-six,  twenty-one,  thirty-four,  and  "a  young  woman." 

§  These  points  and  several  others  are  fully  put  forward  in  Mr.  Holmes's  paper.  Prof. 
Loreta  moreover  points  out  that,  if  the  mechanical  obstruction  has  lasted  sufficiently 
long,  disease  of  the  coats  will  ultimately  take  place,  thus  rendering  examination  of  the 
vomit  alone  fallacious; 


688  OPERATIONS    ON    THE    ABDOMEN. 

(2)  Failure  of  Previous  Treatment. — If  this,  carefully  persevered 
with,  and  including  washing  out  the  viscus,  has  failed  to  prevent 
emaciation  and  exhaustion  ;  if  the  vomiting  is  so  constant  as  to  make 
it  certain  that  rectal  nourishment  will  shortly  have  to  be  resorted  to, 
the  time  for  operative  measures  has  come. 

Operation. — The  stomach  should  be  well  washed  out*  a  few  days 
before,  and  also  on  the  morning  of  the  operation,  with  dilute  solutions 
of  boracic  or  salicylic  acids,  and  the  time  fixed  should  be  as  early  as 
possible  in  the  day.  The  previous  meals  should  be  fluids,  small  in 
amount  and  readily  digested.  The  skin  being  cleansed,  an  anaesthetic 
given,  and  the  parts  relaxed,  an  incision  about  5  inches  long  is  made 
on  the  right  side  of  the  middle  line,  from  a  point  about  1  inch  below 
and  outside  the  xiphoid  cartilage  to  one  just  below  the  cartilage  of  the 
ninth  rib.  Haemorrhage  is  arrested  before  the  peritoneum  is  opened, 
and  one  or  two  fingers  introduced  to  feel  for  and  examine  the  pylorus. 
No  definite  tumor  will  probably  be  felt,  but  distinct  hardness  of  the 
pylorus.  If  the  omentum  is  adherent  to  the  stomach,  it  must  be  sep- 
arated after  both  this  and  the  pylorus  are  drawn  out  of  the  wound. 
Sponges  are  now  most  carefully  packed  around  the  pylorus,  and  the 
stomach  is  opened,  with  blunt  scissors,  about  the  centre  of  its  anterior 
aspect,  but  rather  nearer  to  its  pyloric  end.f  Any  bleeding  points 
are  secured  by  Spencer  Wells's  forceps  ;  then  the  right  index  examines 
the  condition  of  the  pyloric  orifice.  While  attempts  are  made  to 
dilate  it,  this  end  of  the  stomach  is  steadied  by  the  left  hand.  Much 
gentleness  and  patience  must  be  used  in  applying  the  great  force 
which  is  often  required  for  dilatation.  Mr.  Haggard,  finding  that  he 
could  not  introduce  his  finger,  used  a  pair  of  dressing-forceps,  and, 
having  thus  started  the  dilatation-,  followed  it  up  by  the  passage  of  a 
female  urethra  dilator  (probably  having  guarded  the  blades  with 
drainage-tube),  and  dilated  gradually  till  he  was  able  to  get  his  "  index 
and  next  finger  into  the  duodenum  without  feeling  them  at  all  tightly 
packed."  Prof.  Loreta,  in  his  first  case.|  having  introduced  his  right 
index,  found  that  "  no  force  that  could  be  safely  used  succeeded  in 
dilating  it  till  the  left  index  was  also  introduced  and  employed  to 
steady  the  pylorus.  When  this  was  done,  the  end  of  the  right  fore- 
finger was  gradually  squeezed  through  the  aperture.  Then  the  finger 
was  used  to  hook  down  the  pylorus  towards  the  abdominal  wound,  a 
manoeuvre  which  enabled  the  operator  to  get  the  left  index  also  through 
the  pylorus.     But  it  was  still  exceedingly  difficult  to  effect  any  sepa- 

*  This  may  also  bring  about  some  contraction  of  the  visciis. 
f  Of  course,  any  hirge  vessels  will,  as  far  as  possible,  be  avoided. 
X  The  patient  was  aged  forty-seven,  and  symptoms  of  dyspepsia  had  lasted  twenty 
years. 


DILATATION    OF    THE    CARDIAC    ORIFICE.  689 

ration  of  one  finger  from  the  other,  so  great  was  the  resistance,  not 
only  of  the  sphincter  itself,  but  also  of  the  coats  of  the  stomach  and 
duodenum.  The  attempt  at  dilatation  threw  the  muscular  fibres 
into  spasmodic  action,  which  quite  overcame  all  the  force  that  could 
be  exerted.  Three  such  attempts  were  made  in  vain,  but  then  the 
pylorus  began  slowly  to  jdeld  to  the  force  employed,  which  Avas  very 
consideral)le.  At  length  a  sensation  was  experienced,  'showing  that 
the  tissue  was  so  far  distended  that  it  could  not  obey  the  dilating 
finger  further  without  being  torn.'  The  fingers  were  now  kept  apart 
for  a  short  time,  and  the  spectators  noted  that  one  finger  was  about  8 
centimetres  (more  than  3  inches)  from  the  other."  ^ 

The  wound  in  the  stomach  is  next  closed  with  Lembert's  suture,  of 
carbolized  silk;  or  the  method  employed  by  Mr.  Thornton,  p.  686, 
may  be  made  use  of.  The  suture  should  pass  through  any  points  that 
still  bleed  after  forcipressure  is  stopped.  If  any  ligatures  are  really 
required,  fine  chromic  gut  should  be  used.  Perhaps  the  introduction 
of  a  sponge  during  the  insertion  of  the  sutures  may  facilitate  this  step 
by  everting  the  mucous  membrane.  When  the  stomach  is  soundly 
closed,  the  sponges  are  removed  from  the  peritoneal  cavity ,t  the  viscus 
replaced,  and  the  wound  in  the  abdomen  carefully  closed. 

The  after-treatment  will  be  much  the  same  as  for  gastrotom}-,  p.  686. 
Prof  Loreta  seems  to  feed  his  cases  by  the  mouth  very  early — "  on 
the  fourth  day  "  (Haggard) ;  according  to  his  own  paper,  on  the  same 
evening,  in  his  first  case,  every  half  hour  he  gave  teaspoonfuls  of  the 
yolk  of  an  egg  beaten  up  with  Marsala.  Mr.  Haggard  allowed  nothing 
but  ice  to  enter  the  mouth  till  the  seventeenth  da3\  The  condition  of 
the  patient,  and  the  way  in  which  enemata  are  retained,  must  decide 
this. 

It  should  be  noted  that  in  this  case  the  haemorrhage  had  been 
troublesome.  Thus  "  terrific  bleeding  followed  the  incision  "  into  the 
stomach,  and  was  difficult  to  arrest  completely  during  the  suturing  of 
the  stomach.  Ptire  blood  was  vomited  on  the  third  day,  and  about 
two  teaspoonfuls  on  the  sixth. 

DILATATION  OF  THE  CARDIAC  ORIFICE. 

This  operation,  introduced  by  Prof  Loreta  X  for  non-malignant 
stricture  of  the  oesophagus,  and  successfully  performed  by  him  in  at 
least  four  cases,  seems  to  me  to  stand  on  quite  a  different  footing  to 

*  However  the  dilatation  is  effected   it  should  be  kept  up  for  a  few  minutes. 

t  If  any  cleansing  of  the  peritoneum  is  required,  this  will  be  done  now.  To  prevent 
anv  chance  of  leakage,  sutures  should  be  placed  at  the  very  angles  of  the  wound,  or 
even  beyond  them,  as  recommended  by  Sir  W.  MacCormac  in  suture  of  the  bladder 
(Fig.  107). 

X  In  1885,  as  mentioned  by  Mr.  Holmes  {loc  supra  cit.). 

44 


690  OPERATIONS  ON  THE  ABDOMEN. 

the  other  as  to  nsefuhiess.  In  the  first  case  the  inventor  thinks  that 
instrumental  dilatation  of  the  oesophagus  through  a  wound  in  the 
stomach  is  much  preferable  to  gastrostomy,  owing  to  the  almost  uni- 
form fatality  of  the  latter  operation.  In  this  he  seems  ignorant  of  the 
results  obtained  in  this  country  in  favorable  instances,  and  of  cases 
in  which  the  rest  given  by  gastrostomy  has  enabled  surgeons  to  dilate 
an  innocent  stricture  previously  impassal)le,  and  to  close  the  gastric 
fistula  later  on  (p.  684).  Furthermore,  it  remains  to  be  proved  how 
far  strictures  of  the  oesophagus  thus  treated  can  be  considered,  as  Prof. 
Loreta  chiims  for  his  operation,  radically  cured.  For  the  surgeon  is 
here  not  able  to  get  as  directly  at  the  disease  as  in  dilatation  of  the 
pylorus,  and  Prof.  Loreta  allows  in  another  part  of  his  paper  that  the 
cure  here  may  be  only  transitory  and  partial,  as  in  the  case  of  the 
cardia  the  surgeon  loses  the  peculiar  sensation  to  his  fingers  of  fibres 
BO  far  stretched  as  to  have  entirely  lost  their  tonicity  and  power  of 
resilience.  It  will  probably  be  well  to  keep  up  the  dilatation  of  a 
stricture  thus  commenced  from  the  stomach  by  means  of  l>ougies 
passed  from  the  mouth. 

Operation. — The  following  account  is  from  that  given  in  Mr. 
Holmes's  paper  of  the  first  case  thus  operated  on  by  Prof.  Loreta.* 
The  patient,  aged  twenty-four,  had  swallowed  caustic  alkali.  At- 
tempts to  dilate  the  stricture  by  bougies  were  unsuccessful,  and  at 
last  it  became  impossible  to  pass  any  instrument.  The  point  at  which 
the  sound  was  arrested  seemed  to  correspond  with  the  fourth  dorsal 
vertebra.  The  patient  was  entirely  unable  to  swallow,  and  emaciation 
had  become  extreme.  Eleven  months  after  the  injury  an  incision 
about  5  inches  long  was  made  from  the  xiphoid  cartilage  downwards 
and  to  the  left.  Some  difficulty  was  met  with  in  finding  the  stomach, 
owing  to  its  contraction  and  the  way  in  which  the  liver  overlapped 
it ;  but  at  length  the  operator  succeeded  in  drawing  the  greater  part 
of  the  stomach  out  of  the  wound,  and  a  longitudinal  incision  was 
made  through  its  walls  between  the  two  curvatures,  having  its  upper 
end  as  near  the  cardia  as  possible.  The  next  step  was  to  find  the 
orifice  of  the  oesophagus,  in  order  to  introduce  the  dilator;  but  this 
involved  considerable  difficulty,  and  the  search  was  interrupted  by  a 
considerable  quantity  of  bile,  which  regurgitated  from  the  duodenum 
into  the  stomach.  At  length,  by  searching  with  the  left  index  be- 
tween the  under-surface  of  the  liver  and  the  small  curvature  of  the 
stomach,  the  end  of  the  oesophagus  was  found.  Then  the  distended 
stomach  was  kept  drawn  down  by  an  assistant  while  the  operator 
introduced  a  dilator  (something  like  that  of  Dupuytren  for  lithotomy). 

*  Four  cases  in  Prof.  Loieta's  hands,  and  two  under  other  Italian  surgeons,  all 
recovered. 


EXCISION    OF   THE   PYLORUS.  691 

The  wound  was  then  sewn  up  and  the  stomach  returned.  The  pa- 
tient rallied  well,  and  in  six  hours  SAVallowed  some  soup,  with  the 
yolk  of  an  egg,  to  his  great  joy,  as  for  twelve  montlis  he  had  been 
unable  to  do  more  than  swallow  mouthfuls.  Recovery  was  complete 
in  about  eighteen  days,  but  on  the  fourth  day  after  the  operation  he 
was  seized  with  dyspnoea  and  abundant  mucous  expectoration  from 
the  trachea  and  bronchi.  This  same  disturbance  took  place  in  another 
case.  Prof.  Loreta  is  uncertain  whether  it  was  due  to  irritation  or 
paralysis  of  the  sympathetic  or  vagus  during  the  dilatation,  or  to  in- 
flammatory exudation. 

EXCISION  OF  THE  PYLORUS. 

This  operation,  which  we  owe  especially  to  German  surgeons,  Bill- 
roth, Woelfier,  Gussenbauer,  and  v.  Winiwarter,  cannot  yet  be  said  to 
be  definitely  accepted  in  English  surgery.  To  my  mind,  the  very 
high  mortality  and  the  raj^idity  of  recurrence  render  it  extremel}' 
doubtful  whether  this  operation  should  ever  be  performed,  even  in 
the  most  exceptional  cases.  But  I  ought  to  state  that  this  is  the  out- 
come of  an  examination  of  published  cases,  and  not  from  any  per- 
sonal experience  of  the  operation. 

Indications. — Is  the  operation  ever  justifiable?  and,if  so,  in  what 
cases  ?  AMiat  are  the  results  and  the  mortality  f  Dr.  Winslow  (Avier. 
Journ.  Med.  Sci,  1885,  N.S.,  vol.  Ixxxix.  p.  345)  has  collected  fifty-five 
cases  in  which  pylorectomy  was  performed  for  cancer.  Of  these, 
forty-one  died  from  the  effects  of  the  operation,  giving  a  mortality  of 
about  76  per  cent.  Mr.  Butlin  (Oper.  Surg,  of  Malig.  Dis.,  p.  217) 
quotes  Bramer  (C'en<. /.  C/»V.,  1885,  p.  548)  as  having  collected  seventy- 
two  cases  of  pylorectomy  for  cancer,  of  which  fifty-five  died  from  the 
operation,  a  mortality  again  of  about  76  per  cent. 

Duration  of  Cure. — Mr.  Butlin  (loc.  supra  cit.)  shows  that  all  the 
cases  which  have  been  properly  reported  are  either  dead  or  suffering 
from  recurrence.  All  save  one  died  in  a  period  of  from  four  to 
eighteen  months.  The  exception  was  one  of  Woelfler's,  which  re- 
mained well  for  a  year,  and  then  had  a  recurrence  in  the  cicatrix 
which  was  operated  on.  Later  on  the  groin  glands  became  affected, 
and  four  years  after  the  pylorectomy  the  patient  was  dying  slowly  of 
cancerous  recurrence.  In  Mr.  Butlin's  words,  "  There  is  not  one, 
therefore,  of  those  who  recovered  from  the  operation  who  can  be 

claimed  to  have  been  really  cured  of  the  disease Yet  the  cases 

in  which  recovery  from  the  operation  took  place  were,  so  far  as  could 
be  judged,  singularly  favorable  for  the  operation.  In  the  ver}^  large 
majority  of  them  the  disease  was  very  limited  in  extent,  Avas  not 
complicated  by  adherence  to  the  surrounding  parts,  while  the  glands, 
as  far  as  could  be  seen,  were  not  aff"ected  by  the  cancer." 


692  OPERATIONS  ON  THE  ABDOMEN. 

Mr.  Butlin  goes  further  when  he  states  his  belief  that,  while  no 
patients  have  been  cured  b}'  this  operation,  the  relief  it  gives  is  not 
likely  to  be  abiding,  as  the  recurrence  in  several  has  taken  place 
in  situ,  and  that  this  causes  as  much  suffering  as  the  primary  disease. 

With  regard  to  statistics,  it  should,  I  think,  always  be  remem- 
bered— (1)  that  a  very  large  number  of  these  cases  have  been  treated 
by  hands  especially  practiced  in  this  operation,  and  yet  the  mortality 
is  extremely  high ;  (2)  that  the  statistics  do  not  give  the  whole  mor- 
tality, as  it  is  highly  probable  that  a  large  number  of  operations 
have  been  performed  with  unsuccessful  results,  and  therefore  not 
published. 

Time  alone  will  show  whether  the  above  adverse  opinion  is  un- 
justifiable. Any  surgeon  deciding  to  operate  will  weigh  carefully  the 
following  in  a  case  of  undoubted  malignant  obstruction. 

i.  Is  the  mass  localized  to  the  pylorus  ? — i.e.,  how  far  is  it  (a)  with- 
out any  secondary  deposits  ?  (,5)  free  from  adhesions  ?  It  is  probably 
quite  impossible  to  be  certain  as  to  these  points.  While  in  many 
cases  cancer  of  the  pylorus  may  remain  long  limited  to  the  pylorus 
itself,  it  is  very  liable  to  infect  the  lymphatic  glands  around  the  head 
of  the  pancreas,  and  to  cause  secondar^^  growths  in  the  liver  and 
other  parts.  Adhesions,  too,  are  very  frequently"^  met  with  between 
the  stomach  and  tlie  colon,  pancreas,  and  liver.  The  following  cases 
show  how  easily  the  surgeon  may  be  mistaken  in  these  points.  In 
Mr.  Southam's  patient  (Brit  Med.  Journ.,  July  29, 1882 — an  instructive 
paper,  from  which  I  shall  again  quote  later),  aged  forty-three,  though 
the  hard  nodular  mass  in  the  situation  of  the  pylorus  moved  with 
respiration,  and  shifted  as  the  patient  moved  from  side  to  side,  though 
the  symptoms  were  only  of  four  months'  duration,  and  the  disease 
appeared  to  be  limited  to  the  pylorus,  there  was  a  mass  of  enlarged 
glands  surrounding  the  head  of  the  pancreas,  and  some  slight  adhe- 
sions of  the  stomach  to  these.  Mr.  Morrisf  mentions  a  patient  in 
whom,  though  the  growth  could  be  easily  moved  in  different  direc- 
tions, it  was  found  so  firmly  adherent  that  the  operation  had  to  be 
abandoned. 

Mr.  Morris  gives  also  the  following  instructive  case  :  "  A  man 
under  my  care  in  the  ^Middlesex  Hospital,  with  a  movable  cancerous 
mass  in  the  pyloric  region,  consented  to  the  operation  of  pylorectomy  ; 
his  strength  and  general,  as  well  as  local,  condition  seemed  favorable, 
and  all  the  final  preparations  for  the  operation  had  been  made,  when 

*  The  statistics  of  Gussenbaiier  and  Winiwarter  (Langenbeck's  Arch.,  Bd.  xix. 
p.  372,  1876)  show  that,  of  542  cases  of  cancer  of  the  jnlorus,  adliesions  were  present 
in  370. 

t  Intern.  EncycL  Surg ,  vol.  v.  p.  1107.  The  case  was  nnder  Prof.  Lietherin  [Brit. 
Med.  Journ.,  June  3,  1882). 


EXCISION    OF   THE    PYLORUS.  693 

some  increased  distinctness  of  the  superficial  veins  of  the  abdomen, 
and  some  slight  tumidity  in  the  lumbar  regions,  suggested  the  advisa- 
bility of  watching  and  waiting  for  a  day  or  two.  Within  a  week  the 
whole  abdomen  was  distended  with  ascitic  fluid,  the  surface  veins 
Avere  greatly  enlarged,  and  the  lower  limbs  cedematous.  The  patient 
lingered  on  several  weeks,  and  died  with  abundant  secondary  cancer. 
It  is  needless  to  speculate  what  might  have  been  the  result  of  the 
operation  had  it  been  attempted  in  this  case." 

ii.  The  strength  and  age  of  the  patient.  The  general  condition, 
power  of  repair,  etc.,  must  be  sufficient  to  justify  the  patient  being 
submitted  to  an  operation  on  very  vital  parts,  which  will  certainly 
take  an  hour  and  a  half,  and  may  take  between  two  and  three. 

iii.  The  rate  at  which  vomiting,  pain,  and  emaciation  are  in- 
creasing. 

iv.  The  amount  of  dilatation  of  the  stomach,  and  how  far  tliis 
yields  to  washing  out. 

Operation. — For  some  days  before  the  operation  the  stomach 
should  be  washed  out  with  tepid  water,  siphon-fashion,  by  an  india- 
rubber  tube  and  funnel,  till  the  contents  come  out  clear,  this  being 
done  more  frequently  according  to  the  degree  of  dilatation  of  the 
viscus.  Innnediately  before  the  operation*  the  stomach  is  again 
washed  out  with  some  dilute  aseptic  solution,  as  salicylic  acid.  For 
some  time  beforehand  the  patient  must  be  fed  with  that  food  which  is 
found  to  cause  least  vomiting.  In  Mr.  Southam's  case  this  was  found 
to  be  peptonized  milk  and  custard. f  The  bosvels  shovild  be  well 
cleared  out  with  enemata,  and  every  precaution  at  the  time  of  the 
operation  should  be  taken  against  shock — viz.,  wrapping  up  the  pa- 
tient well,  hot  bottles,  bandaging  the  limbs  in  flannel,  keeping  the 
head  low,  the  administration  of  ether  if  possible  for  the  greater  part 
of  the  operation,  and  subcutaneous  injections  of  ether  and  brandy. 

Various  incisions  have  been  made — viz.  (1)  A  vertical  one  in  the 
linea  alba,  above  the  umbilicus.  (2)  A  vertical  one  in  the  right  linea 
semilunaris,  or  through  the  rectus,  tearing  its  fibres  so  as  to  avoid 
haemorrhage  (p.  680).  (3)  Obliquely  from  above  downwards,  and 
from  within  outwards,  between  the  umbilicus  and  right  ribs.  (4) 
More  transversely  over  the  tumor.;|:  Either  of  the  last  two  gives  more 
room,  and  thus  better  access  to  the  growth.     But  as  both  are  accompa- 


*  In  Mr.  Soiitham's  case  the  need  of  tliis  final  washing  was  proved  by  the  fact  that 
a  quantity  of  dark-colored  grumous  matter  was  brought  away,  which  otherwise  might 
have  escaped  into  tlie  peritoneal  cavity. 

t  Nothing  should  be  taken  by  tlie  mouth  for  twelve  hours  before  the  operation. 

X  If  this  has  sunk  very  low,  it  m  ist  tirst  be  raised,  if  possible. 


694 


OPERATIONS  ON  THE  ABDOMEN. 


niecl  with  more  haemorrhage,  and  are  more  difficult  to  close* — a  point 
which  maybe  of  much  importance  at  the  close  of  such  an  operation — 
a  free  oblique  incision,  4  to  5  inches  long,  commencing  a  little  to  the 
left  of  the  middle  line,  but  not  completely  dividing  both  recti,  is  to 
be  preferred.  All  hemorrhage  being  first  arrested,  the  transversalis 
fascia  and  peritoneum  are  pinched  up  and  opened  so  as  to  admit  two 
fingers,  which  examine  the  growth,  the  presence  of  adhesions,  enlarged 
glands,  invasion  of  the  liver,  pancreas,  or  colon,  or  curvatures  of  the 
stomach  itself.  If  the  disease  is  so  localized  as  to  allow  the  surgeon 
to  go  on,  the  opening  in  the  peritoneum  is  enlarged  so  as  to  get  a 
better  view  of  the  disease,  and  to  enable  the  mass  to  be  drawn  for- 
wards with  vulsellum-forceps.  This  having  been  done  as  much  as 
possible,  the  stomach  is  packed  around  with  towels  soaked  in  carbolic 
acid  1  in  20  for  some  days,  and  for  an  hour  or  two  in  1  in  40,  or 
sponges,  so  as  to  prevent  any  escape  of  fluids  into  the  peritoneal 
cavity.  The  omenta  are  next  separated  with  scissors,  either  between 
double  ligatures  of  carbolized  silk  or  chromic  gut  previously  passed 
with  an  aneurism-needle,  or  between  large  pairs  of  omental  clamp- 
forceps,  the  tissues  being  cut  piece  by  piece,  and  each  bleeding  point 
taken  up. 

Excision  of  the  Diseased  Pylorus. — Previous  to  this,  towels  or  sponges 
should  be  still  more  carefully  packed  around  the  stomach,  and  the 

Fig.  113.t 


Oblique  division  of  the  stomach  and  duodenum  in  pyloreetomy.  Billroth  in  this  case  made 
half  the  division  of  the  stomach  first,  united  this  with  "  occlusion  sutures,"  next  severed  the 
rest  of  the  stomach,  then  the  duodenum,  finally  uniting  this  to  the  greater  curvature.  (Billroth.) 

duodenum  should  be  secured,  either  with  a  ligature  of  thick  silk  tied 
round  it  well  wide  of  the  disease,  or  by  a  clamp,  as  in  Fig.  104.  The 
ligature  seems  preferable,  as  it  not  only  prevents  escape  of  contents 

*  In  Mr.  Southam's  case,  the  incision,  6  inches  long,  was  made  2  inches  above  the 
umbilicui?,  and  across  both  recti ;  the  contraction  of  these  muscles  led  to  much  difB- 
cnlty  in  adjusting  the  abdominal  wound. 

f  This  and  the  next  four  figures  are  taken  from  Prof.  Billroth's  Clinical  Surgery,  pt.  iii. 


EXCISION   OF   THE   PYLORUS. 


695 


and  controls  hfemorrhage,  but  also  gives  a  secure  hold,  preventing 
the  intestine  slipping,  and  allowing  it  to  be  drawn  over  towards  the 
cardiac  orifice.     The  duodenum  is  then  cut  through,  as  in  Fig.  113, 

Fig.  114. 


Duoflenum  united  to  the  g.-eater  curvature ;  ten  occlusion  sutures  unite  the  upper  part 
of  the  cut  stomach.    (Billroth.) 

with  scissors,  at  least  5  inch  from  the  disease.     This  incision,  oblique, 
so  as  to  diminish  as  far  as  possible  the  difference  in  the  openings  be- 

FiG.  115. 


(Billroth.) 

tween  the  stomach  and  duodenum,  is  made  with  a  series  of  clean 
careful  snips,  any  bleeding  points  being  secured  at  once  with  Spencer 
Wells's  forceps  if  few,  and  with  fine  chromic  gut  if  numerous. 

The  section  of  the  stomach  has  been  made  in  different  ways.  The 
most  usual  one  is  shown  in  Fig.  113.  The  section  is  made  obliquely, 
with  the  precautions  already  given  in  the  case  of  the  duodenum.  As 
the  cut  end  of  the  stomach  is  so  much  larger  than  that  of  the  duodenum, 
the  former  must  be  reduced  by  suturing  part  of  it  before  it  is  completely 
divided.  The  surgeon  will  decide  whether  he  will  unite  the  duodenum 
to  the  greater  or  lesser  curvature,  or  to  the  part  between  the  two.*     In 


*  Prof.  Billroth  prefers  uniting  the  duodenum  to  the  greater  curvature. 


696 


OPERATIONS  ON  THE  ABDOMEN. 


the  former  case  he  cuts  the  stomach  from  above  downwards,  and  from 
left  to  right,  and  it  will  be  well  to  unite  that  part  of  the  stomach  which 
will  be  superfluous  before  the  section  is  completed  (Fig.  114).  The 
same  course  is  followed  if  the  duodenum  is  united  to  the  lesser  curva- 
ture ;  but  liere  the  section  is  made  from  below  u[)wards,  and  from  right 
to  left.  Figs.  115, 116,  show  the  mode  of  uniting  the  duodenum  midway 
between  the  two  curvatures. 

Fig.  116. 


(Billroth.) 

Closure  of  the  Stomach,  and  Union  of  this  and  the  Duo- 
denum.— That  part  of  the  stomach  which  is  superfluous  is  closed 
with  carbolized-silk  sutures,  inserted  by  Lembert's  method,  the  sutures 
being  left  long  and  held  in  forceps,  so  as  to  stead}^  and  move  the 
stomach  as  may  facilitate  its  union  with  the  duodenum.  The  ligature 
on  this  being  removed,  it  is  united  either  to  the  greater  or  lesser 
curvature,  or  centre,  as  follows,  beginning  with  sutures  passed  from 
within  (Fig.  117).     These,  of  fine  carbolized  silk,  are  passed  with  a 

needle  in  a  holder,  first  at  the  cut 
F"^-  ^^''-  edge   of  the   stomach   between  the 

mucous  and  muscular  coats,  carried 
on  between  the  muscular  and  serous, 
then  through  the  same  layers  of  the 
duodenum,  and  finally  brought  out 
between  these  layers  and  the  mucous 
membrane  at  the  cut  edge  of  the 
duodenum.  When  the  posterior 
aspect  of  the  two  viscera  is  thus 
soundly  closed,  the  anterior  one  is 
united  by  Lembert's  suture.  If  the 
cut  mucous  membranes  do  not  come 
accurately  together,  a  few  sutures 
may  be  put  in  here  separately  from  within. 

Care  must  be  taken  in  inserting  the  sutures  to  avoid  the  formation 


Insertion  of  the  posterior  ring  sutures  from 
within.    (Billroth.) 


GASTRO-ENTEROSTOMY.  697 

of  any  folds  (Billroth).  The  same  surgeon  says  it  is  well  to  put  a  few 
additional  superficial  sutures  at  the  point  where  the  borders  of  the 
duodenum  join  those  of  the  stomach.  If  the  stomach  contains  fluid 
in  spite  of  the  washing  out,  it  must  be  mopped  dry  with  carbolized 
sponges  kept  for  this  purpose  alone,  and  it  may  be  a  help  to  introduce 
sponges  into  the  cut  ends  while  the  sutures  are  being  inserted,  with- 
drawing them  before  the  stitches  are  tightened.  The  sutures  being 
carefully  looked  over  and  cut  short,  a  little  iodoform  is  rubbed  in,  the 
sponges  or  towels  removed,  and  the  stomach  replaced.  If  any  fluids 
have  escaped  into  the  peritoneal  cavity,  this  must  be  carefully  cleansed. 
The  abdominal  wound  is  then  closed  in  the  usual  way  and  the  dress- 
ing.s  applied. 

After-treatment. — This  will  be  conducted  on  much  the  same  lines 
as  after  gastrotomy,  p.  686.  Mr.  Butlin  (loc.  supra  cit.)  points  out  that 
these  patients,  much  let  down  and  exhausted,  will  not  last  long  on  the 
administration  of  ice  and  nutrient  enemata  only.  After  the  first 
thirty-six  hours  teaspoonfuls  of  milk  should  be  given  every  half-hour 
or  hour,  gradually  increased  up  to  a  pint  in  twenty-four  hours  at  the 
end  of  a  week. 

GASTRO-ENTEROSTOMY. 

The  object  of  this  operation  is  to  make  an  opening  between  the 
blocked  stomach  and  the  small  intestine  as  high  up  in  the  latter  as 
possible,  so  that  the  food  may  still  find  its  way  into  the  intestine  and 
there  meet  with  the  other  digestive  fluids.  Owing  to  the  great  fatality 
of  pylorectomy,  this  operation,  or  jejunostomy  (p.  699)  or  that  of 
curetting  the  disease  will  probably  take  its  place,  and  not  only  in 
those  cases  in  which  excision  of  the  pylorus  cannot  be  performed 
owing  to  the  condition  of  the  patient,  the  presence  of  adhesions  or 
secondary  deposits,  or  by  the  growth  involving  the  stomach  itself  as 
well  as  the  pylorus. 

Operation. — The  preliminaries  are  the  same  as  those  given  for 
pylorectomy  (p.  693).  The  following  account  of  the  operation  subse- 
quent to  exposure  of  the  ston)ach  is  taken  from  a  very  successful  case 
of  Mr.  Barker's :  *  "  After  pushing  the  omentum,  which  was  not  volu- 
minous, to  the  left,  the  first  part  of  the  jejunum  was  caught  in  the 
fingers,  and  a  loop  drawn  out  of  the  incision.  The  middle  of  the 
antei'ior  surface  of  the  stomach  was  also  drawn  out,  and  supported  all 
round  by  warm  carbolized  sponges.  I  now  passed  a  piece  of  india- 
rubber  tubing  through  the  mesentery  at  each  end  of  the  loop,  and, 
having  emptied  the  portion  of  gut  by  gentle  pressure,  drew  the  ends 
of  the  tubing  tight  enough  to  prevent  access  of  the  contents  of  the 

*  Brit.  Med.  Journ.,  February  13,  1886. 


698  OPERATIONS    OX    THE    ABDOMEN. 

bowel  into  the  loop  to  be  operated  on,  and  fixed  each  piece  of  tubing 
with  catch-forceps.  The  empty  loop  of  gut  was  now  laid  ujion  the 
portion  of  stomach  to  be  opened,  and  a  longitudinal  fold  of  the  latter, 
about  1^  inch  from  the  great  curvature,  was  pinched  up  between  the 
finger  and  thumb  of  the  left  hand,  together  with  the  collapsed  gut. 
I  now  made  an  incision  about  1^  inch  long  in  the  fold  of  the  stomach, 
and  another  corresponding  in  the  approximated  fold  of  gut.  These 
incisions  only  penetrated  through  the  serous  and  muscular  tunics, 
and  left  the  mucous  coat  of  both  viscera  intact  for  the  present.  Still 
holding  the  parts,  as  before,  between  finger  and  thumb,  I  now  united 
the  eorresi>onding  ix>sterior  edges  of  the  wounds  by  a  continuous 
suture,  the  needle  entering  and  emerging  in  each  case  between  mucous 
and  muscular  coats,  and  the  threads  crossing  the  cut  edges  of  the  mus- 
cular and  serous  coats.  In  this  way  the  serous  surfaces  were  closely 
united  from  end  to  end  before  either  viscus  was  opened.  This  row  of 
stitches  (which  were  about  i  inch  apart)  was  carried  about  \  inch 
beyond  each  end  of  the  incision  in  the  coats  of  the  bowel.  The 
moment  had  now  come  to  open  both  the  stomach  and  intestine  com- 
pletely, and  this  was  done  with  a  stroke  of  scissors  through  the 
mucous  coat  in  each  case,  special  sponges  being  ready  to  receive  any 
fluid  which  might  escape.  A  few  drachms  of  s  ecus  entericus  flowed 
from  the  bowel — little  or  nothing  from  the  stomach  opening.  After 
careful  cleansing,  the  anterior  borders  of  both  openings  were  now 
united  by  a  row  of  interrupted  fine-silk  sutures,  introduced  according 
to  Czerny's  method.  When  this  was  completed,  the  two  openings 
were  securely  closed,  but,  as  an  extra  precaution,  the  intestine  was 
turned  over,  and  the  posterior  suture  wae  reinforced  by  a  second  row 
of  interrupted  sutures,  placed  about  i  inch  away  from  the  first.  The 
anterior  was  then  similarly  reinforced  by  a  row  of  continuous  sutures 
taking  up,  as  before,  only  the  serous  and  muscular  tunics.  Lest  there 
should  be  any  '  kinking'  of  the  latter,  as  in  one  of  Billroth 's  cases,  I 
stitched  its  efi"erent  portion  to  the  stomach  wall,  about  f  inch  from 
the  right  extremity  of  the  opening  between  the  stomach  and  jejunum," 

The  rest  of  the  operation  and  the  after  treatment  will  be  much  the 
same  as  that  already  given  (pp.  686,  697), 

Mr,  Barker's  case  soon  began  to  vomit  turbid  fluid,  which  became 
very  fetid — apparently  pancreatic  secretion  mixed  with  bile.  This 
was  checked  by  the  use  of  creosote  and  placing  the  patient  in  the 
semi-recumbent  position,  which,  allowing  the  intestine  to  slip  down, 
caused  its  opening  not  to  be  exactly  over  that  in  the  stomach. 

DUODENOSTOMY. 

This  and  the  following  operation  have  been  proposed,  in  cases 
unsuited  for  pylorectomy,  as  a  means  of  getting  nourishment  into  the 


JEJUXOSTOMY — TREATMENT   OF   GASTRIC   CANCER.  699 

alimentary  canal  below  the  disease,  and  thus  giving  rest  to  the  diseased 
parts.  Time  alone  will  show  how  far  these  are  preferable  to  gastro- 
enterostomy; but  it  is  certain  that  duodenostomy,  which  has  received 
but  little  favor,  is  destined  to  be  dropped.  It  has  the  serious  objec- 
tions that  it  deals  witli  a  fixed  portion  of  intestine,  and  one  into  which 
important  fluids  are  poured,  and  thus  may  readily  escape  from  a  fistula 
made  here.     Furthermore,  all  the  cases  have,  I  believe,  been  fatal. 

JEJUNOSTOMY. 

This  operation  has  been  performed  in  a  few  instances.  One  of  these, 
which  I  had  the  advantage  of  seeing,  was  brought  by  Mr.  Goldmg  Bird 
before  the  Clinical  Society  (Trans.,  vol.  xix.  p.  70).  The  following 
remarks  are  mainly  taken  from  my  colleague's  paper.  Mr.  Golding 
Bird  was  inclined  to  consider  this  operation  as  superior  to  gastro- 
enterostomy as  giving  the  cancer  much  more  complete  rest,  as  avoid- 
ing the  risk  not  only  of  extravasation  of  contents  of  bowel  and  stomach 
contents,  but  also  of  that  obstruction  of  the  colon  which  may  be  found 
to  be  due  to  the  necessary  bringing  up  of  the  small  intestine  from  below 
it.  Finally,  by  feeding  both  toward  and  from  the  duodenum,  perfect 
intestinal  digestion  can  be  carried  on.  This  was  proved  by  the  rapid 
improvement  in  Mr.  Grolding  Bird's  case. 

Operation. — Tke  precautious  as  to  feeding  and  washing  out  the 
stomach  have  been  already  given  (p.  693).  A  vertical  incision  being 
made  in  the  linea  alba  or  right  linea  semilunaris,  and  the  peritoneum 
opened  with  the  precautions  already  given,  the  transverse  colon  and 
great  omentum  being  drawn  up,  the  omentum  jrushed  over  to  the  left, 
the  first  piece  of  small  intestine  which  presented  itself  is  seized.  To 
bring  this  to  the  left,  it  is  felt  closely  attached  to  the  spine  just  above 
the  aorta,  and  thus  recognized  as  the  commencement  of  the  jejunum. 
A  portion  of  this  is  then  drawn  forvv'ard  in  the  lower  angle  of  the  wound, 
while  the  upper  two-thirds  of  this  are  united.  When  this  is  done,  the 
bowel  is  stitched  to  the  edges  of  the  wound  by  interrupted  sutures,  very 
much  as  in  gastrostomy.  The  after-treatment  of  the  two  operations 
would  be  much  alike. 

TREATMENT  OF  GASTRIC  CANCER  BY  THE  USE  OF 

THE  CURETTE. 

Tliis  new  operation  has  been  iiitroduced  by  Prof  Bernays  *  with 
two  most  successful  cases.  As  it  is  not  improbable  that  it  will  replace 
other  operations  here,  it  will  be  briefly  mentioned.  Prof.  Bernays, 
believing  that  cancer  of  the  stomach,  by  the  time  it  comes  under  the 
surgeon's  hands,  has  ceased  to  be  a  local  disease,  and  that  therefore 

*  Annals  of  Surgery,  December,  1887. 


700  OPERATIONS  ON  THE  ABDOMEN. 

radical  extirpation  is  out  of  the  question,  recommends  gastrostomy 
followed  by  curetting.* 

Having  opened  the  peritoneal  cavity — an  incision  to  the  left  of  the 
linea  alba  parallel  with  the  ribs  was  used — the  anterior  wall  of  the 
stomach  was  found,  and  punctured  with  a  trocar  so  as  to  let  off  the 
gas.  The  parietal  peritoneum  was  then  united  to  the  edges  of  the 
wound  and  the  stomach  (about  the  centre  of  its  anterior  surface), 
stitched  most  carefully  to  the  parietal  peritoneum  and  muscles.  The 
wound  was  then  irrigated  with  1  in  20  carbolic  acid,  to  prevent,  by  its 
slightly  caustic  action,  any  infection  from  the  contents  of  the  stomach. 
The  stomach  was  then  opened  for  li  inch,  very  little  bleeding  folloAV- 
ing,  and  the  lips  of  the  stomach  wound  and  that  in  the  skin  united  l)y 
thirty-six  silk  sutures.  The  stomach  was  now  well  washed  out  with 
warm  water,  and  a  soft  growth  felt  nearly  filling  the  pylorus,  but 
leaving  the  lesser  curvature  intact.  With  two  fingers  half  this  was 
now  removed.  Most  profuse  bleeding  followed,  but  ceased  when  tlie 
hard  base  of  the  tumor  was  readied  with  a  sharp  spoon,  and  the 
stomach  was  irrigated  with  cold  carbolized  water  till  this  ran  out  clear. 
Nine  hours  after  the  operation  the  patient  was  allowed  to  take  glasses 
of  milk  at  intervals,  but  none  came  through  the  dressings,  these  not 
being  changed  till  the  fifth  day.  The  fistula  should  be  kept  open  for 
repetition  of  the  curetting.  In  one  case  14  ozs.,  in  the  other  14  drs., 
of  growth  were  removed.  In  the  second  case,  great  difficulty  was  met 
with  in  dilating  the  pylorus,  the  carcinoma  here  being  much  harder 
and  circular.  The  history  of  the  cases  is  not  complete,  but  it  is  clear 
that  very  great  relief  was  given  in  the  few  months  which  had  elapsed 
since  the  operations,  the  patients  gaining  w^eight,  ceasing  to  vomit, 
and  no  longer  needing  morphia. 


CHAPTER  Till. 
EXCISION  OF  THE  SPLEEN. 

Indications. — All  of  these  are  rare,  and  many  of  them  are  still 
doubtful. 

1.  Cystic  spleen.  When  this  is  found  unsuited  for  drainage.  Mr. 
K.  Thornton's  case  of  this  kind  was  the  first  successful  splenectomy 
in  England. 

2.  Injury.  This  has  been  already  alluded  to  when  gunshot  injuries 
of  the  abdomen  were  considered  (p.  672).     Other  cases  in  which  it 

*  Tlie  fact  tliat  cancer  here  grows  towards  the  cavity  of  the  organ,  and  the  relief 
given  by  repealed  curetting  in  uterine  cancer  first  led  him  to  attempt  this. 


EXCISION    OF    THE    SPLEEN.  701 

may  be  called  for  are,  prolapsus  of  a  spleen,  injured  or  not,  through  a 
wound,  rupture  of  the  spleen,  and  stabs  of  this  viscus. 

3.  Movable  or  wandering  spleens.  When  this  condition  causes 
troubles,  analogous  to  those  of  movable  kidney,  not  relieved  by  a  belt. 

The  remaining  conditions  are  much  more  doubtful. 

4.  Malignant  disease.  Primary  sarcomatous  or  carcinomatous 
disease  of  the  spleen  is  extremely  rare.  The  only  case  I  can  quote  is 
one  removed  for  primary  sarcoma  by  Prof.  Billroth  {Lancet^  June  7, 
1884).  Mr.  Butlin,  referring  to  the  same  case,  says  that  it  was  reported 
shortly  after  that  recurrence  had  proved  fatal  in  a  few  months. 

5.  Hypertrophy  of  the  spleen.  The  operation  must  here  be  limited 
to  those  rare  cases  in  which  simple  (non-leuka}mic)  enlargement  of  the 
spleen  resists  other  treatment.  In  Mr.  Thornton's  table,*  in  fourteen 
cases  of  splenectomy  for  ''  Hypertrophy,"  four  were  successful,  and 
ten  fatal. 

6.  Leulvfemia.t  This  ojieration  has  been  so  invarial)ly  fatal  that  it 
ought  to  be  abandoned. 

Operation. — The  preliminary  steps  will  be  directed  to  ensure 
asepsis  and  to  diminish  shock  (pp.  655,  669).  The  incision  has  usually 
been  one  in  the  linea  alba.  That  in  the  linea  semilunaris,  or  one  fur- 
ther out  (Bryant),  from  the  left  anterior  superior  spine  to  the  ribs, 
would  probably  give  better  connxiand  over  the  pedicle.  All  haemor- 
rhage being  stopped,  the  peritoneum  is  opened  freely  and  the  hand 
explores  the  tumor.  Any  adhesions,  as  of  the  overlying  omentum, 
are  separated,  being  ligatured  if  needful.  The  spleen  is  now  brought 
out  of  the  Avound,  the  lower  extremity  first,  and  either  carbolized 
sponges  or  towels  are  carefully  packed  around  it.  This  extraction  of 
the  viscus  must  be  carried  on  with  the  utmost  caution  and  gentleness, 
as  its  frialnlity  ma\'  easily  lead  to  a  tear  and  most  profuse  oozing,  and 
as  dragging  on  the  pedicle  may  easily  induce  collapse  and  is  also 
likely  to  lead  to  some  small  vessels  retracting  from  the  ligatures  as 
they  are  applied,  and  causing  fatal  haemorrhage. 

The  spleen  being  wholly  outside  the  body,  the  most  imi)ortant  part 
of  the  operation,  securing  the  pedicle,  remains.  This  structure,  if 
present,;}:  must  be  carefully  examined.  If  the  patient's  condition  is 
good,  the  safest  plan  Avill  be  to  secure  the  vessels  as  far  as  possible 
separately,  the  pedicle  being  divided,  as  Mr.  Greig  Smith  Qoc.  supra 

*  It  seems  to  me  that  this  distinction  has  not  been  sufficiently  made.  Several  of  the 
cases  operated  on  read  like  an  early  condition  of  lenksemia,  and  in  those  ending  fatally 
the  rapid  onset  of  death  after  the  operation  is  often  snggestive  of  the  ending  of  leukse- 
inic  splenectomy. 

t  Mr.  Greig  Smith  gives  18  cases;  Mr.  Thornton,  13;  Mr.  Collier,  16— all  fatal. 

t  In  a  case  of  Mr.  L.  Browne's  [Lancet,  vol.  ii.  1877,  p.  310)  there  was  no  pedicle  as 
snch,  four  very  large  arteries  being  met  with  and  secured  with  double  ligatures. 


702  OPERATIONS  ON  THE  ABDOMEN. 

cit.,  p.  563)  suggests,  piecemeal  between  pressure-forceps ;  where  there 
is  not  time  for  this,  it  will  be  wiser  to  secure  the  vessels  in  two  or  three 
portions,  transfixing  in  two  places,  and  locking  the  ligatures  (Thorn- 
ton). Carbolized  silk  should  be  used,  fairly  stout,  and  not  tied  too 
tightly  so  as  to  cut  its  way.  However  the  pedicle  is  treated  the  fol- 
lowing precautions  should  be  followed:  (1)  To  prevent  any  tension 
being  exerted  on  the  pedicle  (vide  supra).  (2)  To  secure  every  vessel, 
(3)  To  divide  them,  in  a  relaxed  condition,  at  a  sufficient  distance 
from  the  ligatures.-  (4)  Not  to  include  the  tail  of  the  pancreas.  (5) 
After  all  the  ligatures^  have  been  applied,  it  may  be  well  for  safety  to 
throw  one  round  the  whole.  (6)  Not  to  twist  the  spleen  round  at  all 
in  dealing  with  the  pedicle.* 

The  abdominal  cavity  is  next  cleansed  and  tlie  operation  completed 
as  after  ovariotomy.     The  after-treatment  is  also  much  the  same. 

Causes  of  Death. f — By  lar  the  most  frequent  is  haemorrhage. 
This  may  be  from  the  omentum  adherent  over  the  si>leen,  from  the 
large  vessels  to  this  viscus.  from  some  small  vessel  which  has  retracted, 
from  the  splenic  vein,  or  from  sponge-like  adhesions.  (Bryant.) 


CHAPTER  IX. 


OPERATIONS  ON  THE  LIVER  AISD  GALL- 
BLADDER. 

HYDATIDS.-HEPATIO  ABSOESS.-TAPPING  AND  IN- 
CISING THE  GALL-BLADDER.— REMOVAL  OF  BIL- 
IARY CALCULI. -EXTIRPATION  OF  THE  GALL- 
BLADDER. 

OPERATIONS  FOR  HYDATIDS. 

This  will  include  different  forms  of  puncture,  free  incision,  and 
electrolysis.  While  the  milder  measures  of  puncture  and  electrolysis 
have  proved  successsful,  Ave  do  not  know  for  certain  how  the  death  of 
the  jmrasite  is  brought  about  by  them  in  successful  cases,  and  they 
are  largely  uncertain. 

A.  Puncture. — While  incision  is  the  only  certain  and  reliable 
mode  of  cure,  it  is  worth  while  to  try  the  different  forms  of  puncture, 
especially  in  certain  cases. 

*  Sir  S.  "Wells  {3led.  Times  and  Gaz.,  January  6,  1866,  p.  4)  draws  attention  to  this. 
Having  done  so  in  order  to  bring  the  vessels  into  a  cord,  tlie  splenic  vein  was  ruptnred. 

t  Adeimann,  to  render  splenectomy  safer,  has  suggested  its  performance  in  two 
stages. 


OPERATIONS    FOR    HYDATIDS.  703 

There  is  no  need  to  do  more  than  to  describe  briefly  such  an  opera- 
tion as  this,  and  to  tabulate  the  chief  practical  points. 

The  parts  being  cleansed  and  an  anaesthetic*  given  if  the  patient  is 
very  nervous,  the  surgeon  chooses  a  spot  for  puncture  at  the  most 
prominent  part  of  the  tumor,  satisfying  himself  as  to  dulness.f  If  the 
skin  is  thick  he  makes  a  minute  puncture  with  a  scalpel  and  sends  in 
a  fine  trocar  or  aspirator  needle.  The  quantity  withdrawn  must  vary 
with  the  case,  the  size  of  the  cyst,  the  timidity  of  the  patient,  etc. 
From  six  to  sixty  ounces  are  instances  of  small  and  large  quantities. 
The  aspirator  should,  on  the  whole,  be  preferred,  as  likely  to  remove 
more  fluid,  and  thus,  probably,  more  likely  to  produce  a  cure,  but  as 
the  exhaustion  is  more  likely  to  plug  the  cannula,  a  fine  wire  must  be 
in  readiness. ;{;  Escape  of  bile,  blood,  or  the  setting  up  of  a  cough  are 
indications  for  stopping.  While  the  cannula  is  withdrawn  the  sur- 
rounding parts  should  be  pressed  around  it,  and  rather  depressed,  to 
diminish  the  risk  of  leakage  as  the  cannula  leaves  the  cyst.  The 
puncture  is  then  closed  with  ether  and  collodion,  a  small  pad  of  dry 
gauze,  and  salicylic  wool  comfortably  secured  with  a  many-tailed 
bandage.  A  little  opium  or  morphia  should  be  given  for  the  first 
twenty-four  hours.  The  instruments  used  should  be  scrupulously 
clean,  and  -in  hospital  practice  and  in  towns,  the  additional  trouble 
entailed  by  the  spray  will  not  be  throAvn  away. 

Practical  Points. 

1.  Puncture  alone  is  more  likely  to  be  radically  curative  in  the  fol- 
lowing cases  :  A  small  cyst,  seen  early.  An  acephalocyst.  The  more 
daughter-cysts,  brood-capsules  and  scolices  are  present,  the  less  likely 
is  it  that  puncture  will  suffice. 

2.  Puncture  is  often  very  useful  as  a  means  of  diagnosis  in  these 
obscure  cases,  in  which  h^-datids  of  the  liver  simulate  disease  of  the 
pleura  or  lung. 

3.  Incision  should  be  made  use  of  where  supj^uration  is  present  or 
imminent,  where  tapping  fails,  where  scolices  instead  of  fluid  form  the 
greater  part  of  the  contents  of  the  cyst,  and  where  chest  complications 
are  set  up  by  the  hydatid,  showing  perhaps  a  risk  of  perforation. 

*  It  is  well  to  dispense  with  this,  if  possible,  from  the  possibility  of  leakage  taking 
place  after  the  subsequent  vomiting.  As  an  injection  of  cocaine  will  give  almost  as 
ranch  [lain  as  the  fine  trocar,  the  part  may  be  frozen  with  the  ether  spray  if  needful. 

f  It  tliis  is  presenting  against  the  right  ribs  another  spot  should,  if  possible,  be 
chosen  (foot-note,  p.  704).  Hydatids  of  the  liver  sliould  never  be  explored  or  attacked 
through  the  ribs,  if  another  site  is  obtainable. 

X  Dr.  Fagge  {Medicine,  vol.  ii.  p.  321)  thought  that  the  value  of  the  aspirator  must 
depend  entirely  on  the  position  of  the  hydatid.  If  a  large  part  of  the  cyst  is  outside 
the  liver-substance,  the  aspirator  may  be  used  with  advantage ;  but  if  the  cyst  be  almost 
entirely  buried  in  liver  substance,  Dr.  Fagge  thought  the  possible  suction  on  a  cyst 
surrounded  by  resistent  tissue  must  involve  some  risk  of  setting  up  inflammation. 


704  OPERATIONS  ON  THE  ABDOMEN. 

4.  A  few  weeks  after  puncture  secondary  enlargement  is  often  no- 
ticed. This  is  not  undesirable  as  long  as  it  subsides,  which  it  usually 
will  do  gradually,  being  due  to  inflammation.  On  this  account  Dr. 
Fagge  advises  that  no  second  operation  on  a  hydatid  should  be  per- 
formed within  twelve  months,  unless  suppuration  is  present. 

5.  Leakage  after  puncture  may  be  shown  l>y  fluctuation,  more  or  less 
distinct,  in  the  flanks.  The  result  of  this  seems  to  have  been  variable. 
In  some  cases  it  has  been  absolutely  harmless,  as  in  a  case  of  elec- 
trolysis of  mine  mentioned  below.  In  others  it  has  been  as  certainl}' 
followed  by  fatal  peritonitis. 

6.  Cases  of  hydatids  treated  by  puncture  should  be  watched  for 
some  time  to  make  certain  that  the  cure  is  a  sound  one. 

7.  It  must  not  be  forgotten  in  operating  on  hydatids  that  the  sur- 
roundings are  of  truly  vital  importance,  and  that  sudden  death  has 
followed  an  operation  more  than  once.  Thus,  in  Mr.  Bryant's  case,* 
in  tapping  a  hydatid  cyst,  the  portal  vein  which  had  been  pushed 
upwards  and  forwards  by  the  projection  of  the  cyst  on  the  under  sur- 
face of  the  liver  was  transfixed.  Death  followed  in  five  minutes,  and 
was  thought  by  Dr.  Fagge  to  be  due  to  hydatid  fluid  being  sucked 
into  the  vein  as  the  trocar  was  withdrawn. 

A  Russian  case  was  published  {Load.  Med.  Record^  1885,  p.  414)  in 
which  the  pulse  suddenly  stopped  while  the  cyst,  which  had  been  ex- 
posed'by  abdoininal  section,  was  being  stitched  to  the  incision.  At 
the  post-mortem,  a  crumbled  echinococcus  had  made  its  way  into  the 
right  auricle,  and  a  fragment  of  one  into  the  right  division  of  the  pul- 
monary artery,  by  an  opening  between  the  thinned  cyst  and  the 
inferior  vena  cava.f 

B.  Incision. — The  indications  for  this  in  preference  to  tapping  have 
been  given  above  (p.  703).  It  may  be  performed  in  one  or  two  stages.^ 
Surgeons  owe  their  knowledge  of  the  safety  of  the  one-stage  method  to  Mr. 
Lawson  Tait.  The  operation  is  thus  performed:  The  parts  being 
cleansed  and  the  other  preliminary  steps  taken,  the  surgeon  makes  an 
,  incision  about  4  inches  long  over  the  most  prominent  part  of  the  swell- 
ing §  (previously  carefully  percussed),  down  to  the  peritoneum;  all 

*  Clin  Soc.  Trans.,  vol.  xi.  p.  230. 

t  Mr.  Willett  {Brit.  Med.  Jotirn.,  November  13, 1886)  mentioned  a  case  in  wliicii  he 
had  to  aspirate  a  doubtful  swelling  of  the  liver.  He  used  an  ordinary-sized  needle, 
and  within  two  minutes  the  patient  was  dead.  It  turned  out  to  be  a  case  of  malignant 
disease.  No  large  vein  had  been  pricked,  and  there  was  no  haemorrhage.  The  fatal, 
sudden  syncope  seemed  due  to  the  impression  made  on  the  nervous  system  through  tlie 
solar  plexus. 

X  The  operation  by  one  stage  is  called  by  some  hepatotomy. 

§  This  incision  should  always  be  made  in  front.  Even  if  a  cyst  or  abscess  sliows  its 
greatest  point  of  prominence  through  the  ribs,  it  should  not  be  opened  here  if  possible, 
as  it  is  diflScult  to  ensure  adequate  drainage,  and  the  lai-ge  drainage-tube  nee<lful 
easily  causes  caries  of  the  closely  adjacent  ribs. 


OPERATIONS    FOR    HYDATIDS.  705 

haemorrhage  is  next  arrested,  and  this  layer  carefully  slit  up.  The  liver 
is  now  recognized,  and  carbolized  sponges  or  towels  (p.  655)  are  care- 
fully packed  in  on  either  side  so  as  to  prevent  any  escape  of  fluid  into 
the  peritoneal  cavity. 

The  needle  of  an  aspirator  or  a  fine  trocar  is  then  thrust  in,  and  the 
existence  of  fluid  beneath  thus  verified.  As  the  needle  is  withdrawn 
the  liver  is  incised,  and  a  finger  quickly  plugs,  and  then  enlarges  to  H 
inch,  the  opening  made  by  the  knife.  Hsemorrhage,  if  free,  is  easily 
arrested  thus,  or  by  sponge-pressure.  Escape  of  fluids  into  the  peri- 
toneal cavity  is  prevented  by  the  use  of  the  sponges  already  mentioned, 
by  an  assistant  keeping  the  edges  of  the  wound  carefully  adjusted  to 
the  liver,  and,  lastly,  by  the  next  step,  which  consists  in  hooking  up 
the  opening  in  the  liver  with  the  finger  or  forceps,  and  in  stitching  the 
edges  of  the  wound  in  the  liver  to  that  in  the  abdomen  with  a  contin- 
uous suture  of  carbolized  silk.  In  inserting  this  care  must  be  taken  to 
unite  peritoneum  to  peritoneum,  and  to  take  up  a  sufficiency  of  tissue 
by  inserting  the  needle  well  away  from  the  edges  of  the  wound.  As 
the  suture  is  inserted  the  sponges  must  be  gradually  Avithdrawn,  and 
if  the  fluid  escapes  very  freely  it  ma}^  be  well  to  turn  the  patient  over 
on  his  side.  Any  scolices  which  are  within  reach  are  next  removed, 
and  if  the  cyst  is  firmly  stitched  and  the  patient's  condition  good,  the 
contents  of  the  hydatid  may  be  cleared  out  with  sponges  on  holders, 
aided  by  scoops.  All  handling  must  be  of  the  gentlest.  A  large  drain- 
age-tube is  then  inserted,  and  dry  sal  alembroth  or  iodoform  gauze 
dressings  applied. 

Operation  by  Tivo  Stages. — This  operation,  based  on  the  readiness  with 
which  two  peritoneal  surfaces  adhere,  is  a  very  satisfactory  one,  being 
free  from  any  risks  of  escape  of  blood  or  other  fluids  into  the  perito- 
neal cavity.  I  thus  performed  it  in  two  cases  of  hydatid  of  the  right 
lobe  under  the  care  of  my  colleagues  Dr.  Pye  Smith  and  Dr.  F.  Taylor. 
An  incision,  4  inches  long,  was  made  through  the  abdominal  wall,  about 
2  inches  to  the  right  of  the  middle  line,  from  just  below  the  ribs  to  the 
level  of  the  umbilicus.  All  bleeding  being  carefully  stopped,  the  peri- 
toneum was  picked  up  and  slit  open.  The  liver,  recognizable  by  its 
characteristic  color,  was  at  once  seen  moving  with  respiration.  To 
make  certain  of  the  position  of  the  fluid  a  fine  trocar  was  now  thrust 
in,  one  or  two  carbolized  sponges  being  first  inserted.  In  one  case, 
which  was  crammed  with  scolices,  very  little  fluid  escaped,  in  the  other, 
an  acephalocyst,  the  fluid  spirted  out  under  the  high  pressure  not  un- 
frequently  met  with.  After  8  ozs.  had  been  withdrawn,  any  leaking  was 
stopped  by  sponge-pressure,  the  parietal  peritoneum  was  stitched  to 
the  edges  of  the  wound  by  a  few  points  of  chromic  gut  suture,  the 
sponges  removed,  and  dry  gauze  dressings  firmly  bandaged  on  with  a 
good  deal  of  pressure  so  as  to  keep  the  abdominal  wall  as  far  as  pos- 

45 


706  OPERATIONS    ON    THE    ABDOMEN. 

sible  in  contact  with  the  liver*  On  the  third  day  the  operation  was 
completed  by  incising  tlie  liver,  now  well  adherent,  and  inserting  a 
large  drainage-tube.  Both  cases  did  well,  though  very  sloAvly.  One, 
a  woman,  three  months  pregnant  at  the  time  of  the  operation,  went 
her  full  time  subsequently. 

C.  Electrolysis. — This  mode  of  treatment  was  used  by  Dr.  Fagge 
and  Mr.  Durham  in  eight  cases,  and  the  results  brought  before  the 
Medico-Chirurgical  Society .f  The  modus  operandi  here  is  uncertain,  as 
in  puncture,  but  it  seems  probable  that  neither  the  electrolytic  action 
nor  the  leakage  of  fluid  into  the  peritoneal  cavity,  but  the  puncture 
alone  of  the  needle  is  the  essential  element. J  This  being  so,  and  the 
method  requiring  special  instruments,  it  has,  I  believe,  fallen  into 
abeyance.  In  one  case,  a  patient  of  Dr.  Moxon's,  I  made  use  of  this 
method  after  previous  tapping  had  failed.  The  steps  taken  by  Dr. 
Fagge  and  Mr.  Durham  were  carefully  followed.  Two  electrolytic 
needles  were  passed  into  the  most  prominent  part  of  the  swelling, 
about  2  inches  apart,  and  Avere  then  attached  to  wires  both  connected 
with  the  negative  pole  of  a  galvanic  battery  of  ten  cells.  A  moistened 
sponge  connected  with  the  positive  pole  was  placed  on  the  skin  at  a 
little  distance.  The  current  was  passed  for  half  an  hour.  The  punc- 
tures were  then  closed  with  a  pad  of  gauze.  Indistinct  fluctuation 
could  be  made  out  in  the  flanks  during  the  next  forty-eight  hours. 
There  was  no  constitutional  disturbance,  the  tumor  steadily  diminished 
in  size,  and  a  good  recovery  took  place. 

HEPATIC  ABSCESS.— HEPATOTOMY.i 

As  tapping  by  a  trocar,  and  draining  the  abscess  by  the  cannula 
left  in,  or  a  drainage-tube  passed  through  the  cannula,  this  being  then 
withdrawn,  is  unsatisfactory,] |  and  as  the  use  of  the  aspirator  here  is 

*  One  case  bulged  out  the  riglit  lower  ribs  most  markedly.  For  reasons  already 
given,  I  preferred  to  attack  it  in  the  front  of  the  right  hypochondrinm.  On  exposing  the 
liver,  a  hydrocele  trocar  passed  through  li  inch  of  hepatic  tissue  before  fluid  was 
reached.  Very  little  hsemorrhage  followed  the  completion  of  the  second  stage  of  the 
operation. 

f  Trans.,  vol.  liv,  p.  1. 

X  Thus,  in  a  case  of  Dr.  Playfair's,  related  in  the  appendix  to  Dr.  Fagge's  paper, 
progressive  diminution,  almost  identical  to  that  noticed  after  electrolysis,  followed 
acupuncture  only. 

^.  This  term  is  also  applicable  to  incisions  of  tlie  liver  for  hydatids. 

li  Thus  (1)  the  cannula  and  tube  may  slip  out.  (2)  The  drainage  is  inefficient. 
(3)  If  the  pus  leaks  into  the  peritoneal  cavity,  it  does  so  unseen.  (4)  The  trocar  may 
puncture  important  parts.  Thus,  in  one  case  of  Mr.  K.  Thornton's  {Mtd.  Times  and 
Gaz.,  1883,  vol  i  p.  89),  the  omentum,  containing  large  veins,  lay  over  the  liver.  (5) 
Puncture  and  drainage  would  be  quite  insufficient  in  cases  where  more  than  one 
abscess  existed. 


HEPATIC   ABSCESS.  707 

mainly  exploratory  and  palliative,  it  is  to  a  free  incision  that  we  must 
look  for  a  permanent  cure.     This  may  be  employed  in  three  wrjs — 

1.  Direct  incision  and  drainage,  when  tenderness,  oedema,  and 
redness  make  it  probable  that  adhesions  exist.  This  needs  no  further 
comment. 

2.  Incision  and  drainage  by  abdominal  section,  in  two  stages. 

3.  Incision  and  drainage  by  abdominal  section,  at  one  sitting. 

The  methods  of  treating  an  hepatic  abscess  by  abdominal  section, 
whether  in  one  or  two  stages,  have  already  been  spoken  of  at  p.  704, 
under  the  heading  of  Hydatids.  They  have  the  following  advantages 
over  other  modes  of  treatment:  (a)  The  benefit  of  a  free  incision  and 
thorough  drainage ;  (6)  the  surgeon  can  see  what  structures  he  is  deal- 
ing with  (see  last  foot-note  on  p.  706) ;  (c)  bleeding  from  the  liver  can 
be  seen  and  arrested  ;  (c/)  if  pus  escapes  into  the  peritoneal  cavity  this 
can  be  cleansed. 

Ver}'  little  need  be  said  here  of  the  treatment  by  abdominal  section 
in  addition  to  that  alread}^  written  at  p.  704.  In  the  two-stage  method 
the  surgeon  will  open  the  peritoneal  cavity,  suture  the  jDarietal  peri- 
toneum to  the  edges  of  the  wound,  insert  some  gauze,  and  endeavor, 
by  well-adjusted  bandaging,  to  keep  the  abdominal  parietes  in  contact 
with  the  liver,  opening  the  abscess  on  or  after  the  third  day. 

In  the  method  by  direct  incision,  a  free  incision  of  4  or  5  inches  is 
made,  and  the  position  of  the  pus  being  verified  b^'  a  fine  trocar  or 
aspirator-needle,  some  soft  carbolized  sponges  (previously  counted) 
are  carefully  packed  around.  The  abscess  is  then  incised,  and  the 
opening  at  once  plugged,  and  freely  dilated  with  the  finger.  Any 
escape  of  pus  into  the  peritoneal  cavity  is  prevented  (1)  by  the  careful 
sponge-packing ;  (2)  by  the  finger  hooking  up  the  liver  against  the 
wound ;  (3)  by  an  assistant  keeping  steadih'  the  parietes  against  the 
liver ;  (4)  by  seizing  the  edges  of  the  liver  with  catch-forceps  and  so 
keeping  them  against  the  parietes.  Haemorrhage  is  prevented  by  the 
above  forceps  or  sponge-pressure.  When  the  abscess  is  empty,*  its 
opening  is  plugged  with  a  sponge,  and  the  liver  and  the  parietes  being 
still  kept  accurately  together,  the  sponges  first  inserted  are  removed,! 
and  the  edges  of  the  liver  wound  stitched  with  carbolized  silk  passed 
with  curved  needles  on  a  holder,  to  the  edges  of  the  abdominal  inci- 

*  Mr.  Greig  Smith  (Abdotn.  Surg.,  p.  527)  advises  that,  if  the  abscess  does  not 
empty  itself  readily,  a  large  tube  lying  in  carbolic  lotion  may  be  pinched  at  the  end, 
and  when  placed  at  the  bottom  of  the  abscess  will  act  as  a  siphon.  He  also  draws 
attention  to  the  need  of  exploring  the  abscess  cavity  for  signs  of  a  second  abscess,  and, 
if  this  be  found,  opening  it  with  the  tinger  or  dressing-forceps.  All  manipulations 
now  must  be  of  the  gentlest  for  fear  of  hemorrhage. 

f  If  any  pus  or  bluod  has  escaped  into  the  peritoneal  cavity  this  must  be  now 
cleansed. 


708  OPERATIONS   ON   THE   ABDOMEN. 

sion,  care  being  taken  to  keep  peritoneal  surfaces  well  in  contact.  If 
the  pus  is  fetid,  the  abscess  cavity  should  be  well  irrigated  with  a 
dilute  antiseptic  lotion.  A  considerable  thickness  of  dry  gauze  dress- 
ings will  be  needed  at  first,  easily  renewed  by  means  of  a  many-tailed 
bandage. 

TAPPING  AND  INCISING  THE  GALL-BLADDER.— CHO- 
LECYSTOTOMY.— REMOVAL  OF  BILIARY  CALCULI. 

Indications. — The  justifiability  of,  and  the  indications  for,  the 
above  operations  may  be  considered  together,  depending  as  they 
usually  do  upon  the  presence  and  effects  of  biliary  calculi. 

1.  Gall-stones.*  When  previous  treatment  has  failed  to  relieve  the 
patient  from  repeated  crippling  attacks  of  biliary  colic  and  jaundice 
when  the  hepatic  or  common  duct  is  blocked. 

2.  Dropsy  and  empyema  of  the  gall-bladder.f  This  is  usually  due 
to  impaction  of  calculi,  the  bile  gradually  losing  its  coloring  matter 
and  becoming  more  and  more  mucoid  and  watery,  and  the  increased 
tension  gradually  causing  suppuration. 

3.  Obstruction  in  the  common  duct.  The  most  likely  cause  of  this 
for  the  surgeon  to  deal  with  is  a  calculus.  Very  grave  results,  if  this 
block  be  unrelieved,  are,  jaundice  and  cholaemia  {vide  infra). 

4.  Certain  cases  of  injury  to  the  gall-bladder.  Such  are,  wounds, 
rupture,  if  any  coexisting  lesion  is  not  going  to  be  fatal,  and  bursting 
of  an  empyema  of  the  gall-bladder. 

The  following  indications  for  operation  are  given  by  Mr.  Greig 
Smith  :t 

*  Mr.  Tail  {Lancet,  1885,  vol.  ii.  pp.  239^  424)  divides,  for  practical  purposes,  gall- 
stones into  two  classes — (1)  the  solitary  ;  (2)  the  numerous.  The  former  are  seldom 
more  than  two  or  three  in  number,,  and  often  of  considerable  size.  They  are  liable  to 
be  caught  in  the  cystic  duct,  to  give  symptoms  of  blocking  it,  together  with  distension 
of  the  gall-bladder,  but  no  jaundice,  as  the  bile,  prevented  from  entering  the  gall- 
bladder, flows  constantly  into  the  duodenum.  The  gall-bladder  is  easily  opened,  but 
the  removal  of  the  calculus  from  the  duct  may  be  very  dithcult.  In  the  second  class 
several  hundreds  of  calculi  may  be  present.  As  these  from  their  size  usually  admit 
of  a  flow  of  bile  past  thera,  jaundice  is  seldom  seen,  and  the  distention  of  the  gall- 
bladder is  intermittent.  The  operation  here  differs  considerably.  As  the  gall-bladder 
is  not  distended,  the  diagnosis  is  more  uncertain,  and,  when  the  abdomen  is  opened, 
tjie  gall-bladder  is   less  easily  found.     Care  must   be  taken   that  no  stones  are  left 


t  Dehind. 


f  As  the  diagnosis  of  gall-bladder  swelling  is  not  always  easy,  it  will  be  well  to 
remember  the  direction  in  which  the  gall-bladder  enlarges.  According  to  Mr.  Taylor 
[Brit.  Med.  Journ  ,  1885,  vol.  i.  p.  737),  this  is  in  a  line  drawn  from  the  tip  of  the  right 
tenth  cartilage  to  the  oppositeside  of  the  abdomen,  crossing  the  middle  line  just  below 
the  umbilicus. 

X  Abdominal  Surgery,  p.  541. 


OPERATIONS   ON    GALL-BLADDER    AND    BILE    DUCTS.  709 

"  In  every  case  of  wound  or  perforation  of  the  gall-bladder  operation 
ought  at  once  to  be  performed.  Operation  gives  the  only  chance  of 
recovery.  In  every  case  of  empyema  of  the  gall-bladder  operation  is 
indicated.  Aspiration  is  only  a  temporary  measure,  and  it  is  by  no 
means  free  from  danger. 

"  In  every  case  of  dropsy  of  the  gall-bladder,  operation  is  indicated. 
Aspiration  ma)^  do  no  harm,  and  it  may  detect  the  presence  of  stone. 
But  it  is  useless  towards  the  removal  of  stone,  and,  generally,  it  has 
no  beneficial  effect  on  the  disease. 

"  In  cases  of  cholelithiasis,  tlie  indications  to  operate  must  be  guided 
by  the  effects  produced  by  the  disease.  The  dangejous  sequences  of 
gall-stones  are  frequently  recurring  attacks  of  hepatic  colic,  which 
wear  out  the  patient's  strength ;  jaundice,  proceeding  to  dangerous 
cholsemia,  and  suppuration  in  the  gall-bladder.  The  indication  in 
each  instance  is  strengthened  by  the  presence  of  an  enlarged  gall- 
bladder. 

"  No  general  rule  can  be  laid  down  as  to  the  weight  of  the  indication 
arising  from  hepatic  colic.  After  months  or  years  of  intense  suffering, 
many  patients  get  well,  and  remain  so.  On  the  other  hand,  a  patient's 
life  may  be  rendered  miserable,  or  his  active  existence  as  a  bread- 
winner may  be  cut  short,  by  persistently  recurring  attacks  of  hepatic 
colic.  A  time  then  comes  when  patient  and  surgeon  both  agree  that 
it  is  proper  to  interfere.  In  all  such  cases  the  patient's  desires  must 
have  great  influence  with  the  surgeon. 

"  In  cases  of  persistent  obstructive  jaundice,  operation  is,  at  the  same 
time,  indicated  and  contra-indicated.  Cholsemia,  not  only  as  weaken- 
ing and  depressing  the  patient,  but  also  as  j^redisposing  to  bleeding,* 
is  an  unfavorable  element.  In  only  seven  of  Musser  and  Keen's 
thirty-five  cases  of  cholecyBtotomy  was  jaundicei"  present,  and  five  of 
these  died — half  of  the  whole  mortality.  That  the  jaundice  had  much 
to  do  with  this  excessive  death-rate  there  can  be  no  dispute.  This 
suggests  early  operation,  before  the  patient's  condition  is  lowered  by 
chola^mia. 

"  Where  evidences  of  suppuration  appear  in  •cholelithiasis,  operation 
is  to  be  urged.     Every  day  that  passes  brings  increase  of  danger. 

*  Dr  Miifiser  and  Dr.  Keen  {Amer.  Journ.  Med.  ScL,  October,  1884)  state  that  wlier« 
long-continued  jaundice  has  disorganized  the  blood  there  is  a  marked  hseniorrhagie 
tendency. 

t  Mr.  Tait  (toe.  supra  cit.%  having  met  with  no  history  of  jaundice  in  fifteen  cases  of 
cholecystotomy,  thus  explains  its  absence.  The  common  duct  is  not  so  long  as  the 
books  say  (viz.,  3  inches),  and  it  is  more  easily  dilated  than  the  cystic.  A  stone  passing 
through  the  unyielding  cystic  duct  causes  great  agony,  but  no  jaundice.  As  soon  as 
it  enters  the  common  duct,  tiie  whole  excreting  force  of  tlie  liver  comes  into  play,  so 
that  its  passage  is  more  rapid  and  gives  no  lime  for  jaundice,  which  only  occurs  with 
long  obstructioQ  of  the  cotunwn  duct. 


710  OPERATIONS  ON  THE  ABDOMEN. 

"  In  cases  of  obstruction  of  the  common  or  the  hepatic  duct,  chole- 
cystotomy  may  simply  prevent  death  by  permitting  escape  of  the 
biliary  poison  *  Patients  can  live  without  escape  of  bile  into  the 
intestines.  But  Tait  has  shown  us  how  a  stone  in  the  common  duct 
can  be  crushed,  so  that  even  in  these  cases  cure  may  be  effected. 

"  In  cases  of  obstruction  of  the  cystic  duct,  operation  in  tlie  majority 
of  cases  will  not  only  relieve  pain,  remove  danger  of  suppuration  in 
the  gall-bladder,  but  Avill  also,  in  all  probability,  bring  about  complete 
cure." 

Operations. — Tapping  and  incising  the  gall-bladder,  and  removal 
of  calculi  may  be  considered  together.  It  may  be  stated  at  once  that 
aspiration  by  itself  should  not  be  practiced.  It  is  attended  with  much 
danger,f  and  the  information  given  in  doubtful  cases  can  be  more 
safely  given  by  a  small  exploratory  abdominal  incision. 

The  operation  of  cholecA^stotomy  is  usually  performed  in  one  stage. 
The  abdomen  having  been  cleansed  (p.  581),  the  parts  relaxed,  one  of 
the  following  incisions  is  made  use  of.  The  best  one  is  a  vertical  one, 
3  to  4  inches  long,  either  over  the  fundus  if  the  tumor  is  prominent, 
or  straight  down  from  the  tip  of  the  cartilage  of  the  tenth  rib,  or  one 
in  the  right  linca  sen">ilunaris  ;  finally,  in  the  case  of  those  large  and 
doubtful  swellings,  due  to  distended  gall-bladder,  the  incision  should 
be  made  in  the  linea  alba.  The  peritoneum  being  reached,  any  vessels 
which  have  })een  closed  with  Spencer  Wells'  forceps  are  secured  with 
chromic  gut.  The  peritoneum  is  then  picked  up  and  opened,  and  an 
index  finger  introduced  to  feel  for  the  gall-bladder,  to  which  calculi 
are  often  a  guide.  If  there  is  difficult}^  in  this  stage,  the  liver  edge 
should  be  used  as  a  guide.|     Some  trouble  ma}^  be  given  now  by  the 

*  As  in  cases  where  the  mischief  is  not  due  to  impacted  calculi,  but  to  atresia,  etc., 
after  ulceration. 

t  Thus  in  two  cases  (quoted  by  Mr.  (ireig  Smith),  in  one  of  which  Dr.  Harley 
explored  with  a  fine  aspirator-needle,  after  a  short  interval,  the  patient  died  with 
enteritis  and  peritonitis.  In  a  case  of  Dr.  Keen's  not  a  little  hfemorrhage  and  con- 
siderable local  peritonitis  followed  tiie  use  of  a  hypodermic  syringe.  Furthermore, 
the  utility  of  this  step  is  doubtful,  for  the  point  of  the  needle  may  easily  miss  the  stone. 
Mr.  Greig  Smith  condemns  this  step,  and  Mr.  Meredith  (Did.  af  Surg.,  vol.  i.  p.  284) 
con.siders  it  "  not  altogether  devoid  of  risk."  On  the  other  hand,  Mr.  Morris  seems  to 
consider  it  safe,  and  quotes  a  case  of  Dr.  Dixon's  (Pract.,  April,  1876),  in  which  tlie 
gall-bladder  was  tapped  five  times  with  great  relief  in  a  case  of  obstruction  of  the 
common  duct  with  cancer,  a  total  of  87^  ozs.  being  withdrawn  with  the  aspirator. 

X  In  one  case  of  Dr.  Parkes's  (Trans.  Amer.  Surg.  Assoc,  vol.  iv.  p.  299),  in  which 
there  had  been  a  two-years'  history  of  biliary  colic,  "the  most  careful  and  diligent 
search  failed  to  find  the  gall-bladder,  the  proper  location  of  which  was  plainly  outlined 
and  felt  with  the  finger,  with  reference  to  the  transverse  fissure  and  ligament,  showing 
the  entire  absence  of  the  gall  cyst ;  but  close  to,  and  partly  encroaching  upon,  the 
transverse  fissure  was  found  an  elevated,  resisting  tumor,  the  exact  nature  of  which 
cauld   not   be   determined,   but    probably   contain^ing   biliary  concretions."     It   was 


CHOLECYSTOTOMY.  711 

intestines  concealing  the  gall-bladder,  or  by  the  liver,  if  enlarged,  de- 
scending with  respiration  and  requiring  to  be  pushed  up.  The 
intestines  must  be  kept  out  of  the  way  by  the  use  of  carbolized  sponges 
or  a  towel  (p.  655).  AVhen  the  gall-bladder  is  found,  the  next  thing 
is  to  bring  it  into  tlie  wound.*  If  this  can  be  effected,  any  fluid  con- 
tents are  witlidrawn  with  the  aspirator  to  diminish  the  size  of  the 
swelling.  The  puncture  being  enlarged,!  a  finger  is  inserted  to  feel 
for  calculi.  Any  that  are  well  in  reach  are  removed  by  small  scoops 
or  forceps,^  while  escape  of  any  fluids  into  the  peritoneal  cavity  is 
prevented  by  the  careful  packing  of  carbolized  sponges  or  towels,  and 
by  an  assistant  keeping  the  edges  of  the  wound  in  the  abdomen  and 
gall-blacider  carefully  together.  Before  extraction  of  any  difficult 
calculi  is  attempted,  the  edges  of  the  gall-bladder  should  be  sutured 
to  those  of  the  abdominal  wound  with  a  continuous  suture  of  car- 
bolized silk,  or  with  separate  ones  at  short  intervals,  and  intervening 
ones  of  horsehair  or  fishing  gut.  The  parietal  peritoneum  must  be 
carefully  taken  up,  and  the  sutures  passed  at  a  sufficient  distance  from 
the  edges  of  the  gall-bladder  and  the  incision  in  the  abdominal  wall 
to  ensure  a  good  hold.  The  sutures  should  pass  through  any  bleeding 
points  in  the  cut  gall-bladder,  and,  as  the  stitches  are  inserted,  the 
sponges  are  withdrawn.  A  drainage-tube  is  then  inserted  and  the 
dressings  applied.     These  may  require  frequent  changing  at  first. 

Some  surgeons  have  preferred  to  open  the  gall-bladder  by  two 
stages,  exposing  it  first  and  suturing  it  carefully  to  the  edges  of  the 
wound,  closing  the  angles  of  this  exactly,  and  opening  the  gall-bladder 
a  few  daj's  later. 

A  few  points  still  require  attention.  The  difficulty  of  finding  the 
gall-bladder  and  of  getting  it  up  into  the  wound  has  been  already  re- 
ferred to.  In  one  case,  in  which  Dr.  Parkes  (loc.  supra  cit.)  met  with 
this  latter  difficulty,  owing  to  the  thickening  and  matting  of  the  gall- 
bladder, he  detached  some  of  its  adhesions  to  the  liver  and  passed  a 
silk  suture  through  opposite  sides  of  the  thickened  fundus,  as  far  from 
each  other  as  possible.  The  gall-bladder  was  then  opened  by  cutting 
between  the  sutures,  and  forty-three  stones  removed.  The  opening 
in  the  gall-bladder  was  then  close<],  leaving  an  orifice  at  the  tip  to  in- 

too  near  the  large  bloodvessels  to  admit  of  any  interference  with  it.  Post-mortem 
examination  revealed  remains  of  the  shrunken  gall-bladder,  but  with  no  sign  of  bile  in 
it.     A  gall-stone  lav  at  the  junction  of  the  hepatic  and  common  ducts. 

*  Mr.  Tait  draws  up  the  fundus  of  the  bladder  into  the  wound  cautiously  with  a  pair 
of  forcejis.  Great  care  must  be  taken  not  to  rupture  a  bladder  much  distended,  or  to 
cause  sloughing. 

t  The  escape  of  bile  into  the  peritoneal  cavity  i,-,  prevented  by  packing  sponges 
(previously  counted,  around  the  gallliladder,  and  holding  one  under  it  in  clamp- 
forceps. 

X  Several  special  forms  have  been  invented  by  Mr.  Tait. 


712  OPERATIONS   ON   THE    ABDOME.V. 

sert  a  large  drainage-tube,  some  of  the  highest  sutures  being  passed 
through  the  abdominal  wall. 

Extraction  of  all  the  calculi  is  often  most  difficult,  especially  of  any 
very  far  down  in  the  cystic  duct,  or  of  such  a  one  as  Mr.  Tait  thus 
describes  {Lancet,  August  29,  1885).  The  stone  was  probably  pear- 
shaped,  and  impacted  at  the  orifice  of  the  duct.  "  From  the  long, 
narrow,  funnel-like  cavity  in  which  it  was  lodged,  and  from  the 
mobility  of  the  bladder,  it  was  very  difficult  to  seize,  and,  when  at  last 
I  did  get  hold  of  it,  I  found  it  adherent  to  the  raucous  surface.  I  had 
then  to  consider  the  extreme  likelihood  that  in  removing  this  impacted 
stone  I  might  tear  the  walls  to  which  it  was  attached,  and  thus  cer- 
tainly kill  my  patient.  I  therefore  performed  a  very  careful'and  pro- 
tracted lithotrity,  chipping  little  fragments  off  the  stone  regularly  all 
over  its  exposed  surface,  till  I  had  the  satisfaction  of  lifting  out  its 
nucleus.  I  then  passed  the  blade  of  a  fine  pair  of  forceps  on  each  side 
of  it,  and  by  a  gentle  squeeze  broke  up  the  remainder."  Frequent 
washings  out  were  then  employed.  While  forceps  are  thus  used,  one 
forefinger  is  placed  over  the  stone  to  guard  the  parts  from  undue  vio- 
lence, and  to  dislodge  any  fragments. 

In  another  case  of  a  stone  which  he  could  neither  extract  with  for- 
ceps nor  dislodge,  the  same  surgeon  very  ingeniously  crushed  the  stone 
in  situ  by  means  of  carefully  padded  forceps  applied  outside  the  duct 
walls,  and  then  dislodged  the  fragments  by  finger-pressure. 

The  resulting  biliary  fistula  will  probably  close  in  a  few  weeks  if 
the  ducts  are  now  pervious.*  Through  it  further  attempts  may  be 
made  to  get  rid  of  any  remaining  calculi. f  If  the  wound,  after  closing, 
breaks  open  and  discharges  mucus,  a  stone  is  probably  left  behind  in 
the  gall-bladder. 

While  primary  closure  of  the  gall-bladder  has  been  successful  in  a 
few  cases,  it  is  not  so  safe  a  method,  and  involves  the  risk  of  leaving 
one  or  more  stones  behind. 

Difficulties  of  the  Operation. 

1.  In  this  class  of  patients  the  anaesthetic  may  be  taken  badly. 

2.  A  very  large  amount  of  fat,  and  thus  a  very  deep  wound. 

3.  Crowding  up  of  the  intestines. 

4.  The  gall-bladder  may  be  much  thickened  and  tied  down,  thus 
difficult  to  find  and  impossible  to  bring  up  into  the  wound. 

*  Dr.  Parkes  {Avier.  Journ.  Med.  Sci.,  July,  1885),  in  one  case,  in  wliioh  a  month 
after  the  cholecystotomy  tliere  was  no  evidence  of  bile  entering  the  intestine,  manipu- 
lated a  eteel  sound  (No.  11),  guided  by  a  finger  in  the  peritoneal  cavity,  through  the 
common  duct,  into  the  intestine. 

t  Mr.  G.  Smith  (loe.  supra  clL,  p.  549)  remarks  that,  if  the  gall-bladder  is  adherent 
to  the  abdominal  walls,  any  stones  which  may  subsequently  form  can  be  safely  removed 
through  the  old  scar. 


OVAEIOTOMY.  713 

5.  The  gall-bladder  may  be  much  shrunken,  a  smooth  hard  tumor 
being  all  that  is  felt  in  its  situation.* 

6.  A  stone  may  be  impacted  very  far  back. 

7.  An  enormous  number  of  small  stones. 

CHOLECYSTECTOMY. 

Extirpation  of  the  gall-bladder  was  performed  in  five  cases  by 
Langenbeck,  four  being  successful,  and  one  fatal  from  ulceration  of 
the  bile  duct  brought  about  by  an  undetected  calculus.  Mr.  Greig 
Smith  thus  writes  of  the  operation  :  "  The  indications  given  by 
Langenbeck  are  dropsy,  cholelithiasis,  and  empyema.  These  indica- 
tions are  probably  too  broad.  I  should  limit  the  indications  to  two — (1) 
where  the  bladder,  containing  one  or  more  calculi,  is  so  contracted 
that  its  fundus  cannot  be  sutured  to  the  parietes  without  tearing  its 
Avails ;  (2)  where  there  has  been  perforation  after  ulceration  and  em- 
pyema, and  the  tissues  are  so  thin  or  so  much  inflamed  that  they  will 
not  bear  suturing.  The  operation  need  not  be  difficult.  Separation 
from  the  liver  is  begun  at  the  fundus  and  carried  down  to  the  cystic 
duct.  This  is  divided  between  two  ligatures,  and  the  bladder  removed. 
A  suture  passing  through  the  outer  coats  will  more  thoroughly  close 
the  divided'  end  of  the  duct.  The  incision  will  be  at  least  Ik  inch 
longer  than  in  cholecystotomy  ;  if  additional  room  is  wanted,  Cour- 
voisier's  plan  of  dividing  transversely  the  muscles  a  little  below  the 
ribs  may  be  adopted.  If  the  bladder  is  intimately  attached  to  the 
liver,  a  good  deal  of  ha?morrhage  may  be  expected;  most  of  the 
bleeding  may  be  checked  by  forcipressure,  but  a  few  ligatures  may  be 
called  for.  During  the  operation,  the  edge  of  the  liver  is  pulled  up- 
wards by  a  retractor,  and  the  area  of  operation  is  isolated  by  means 
of  sponges." 

CHAPTER  X. 

OPERATIONS  ON  THE  OVARY. 

OVARIOTOMY.— REMOVAL  OF  THE  UTERINE  APPEN- 
DAGES. 

OVARIOTOMY. 
One  or  two  practical  points  will  be  alluded  to  before  the  opera- 
tion itself  is  described. 

*  In  one  case,  published  by  Dr.  Keen  [Philad.  Med.  Times,  November  14,  1885; 
Ann.  of  Surg.,  January,  1886),  the  gall-bladder  being  displaced,  the  duodenum  was 
opened  by  mistake,  and  sutured.  The  gall-bladder  was  finally  found  far  posterior  to 
its  proper  site,  much  shrunken,  and  closely  contracted  over  two  gall-stones.  The  patient 
died,  fifteen  hours  after  the  removal  of  these,  from  shock  and  a  small  amount  of  after- 
haemorrhage,  presumably  from  vessels  injured  in  lifting  to  the  surface  the  mass  in 
which  the  stones  were  situated. 


714  OPERATIONS  ON  THE  ABDOMEN. 

Question  of  Adhesions. — If  there  is  free  mobility  of  the  cyst  from  side 
to  side,  there  are  no  parietal  adhesions.  In  testing  this,  both  hands 
should  be  employed.  Does  the  tumor  descend  with  a  deep  inspira- 
tion? Here  a  good  light  and  careful  percussion  are  needed.  These 
movements  are  seen  best  when  the  surface  of  the  cyst  is  uneven. 
Presence  of  intestine  in  front  of  the  cyst  can  be  made  out  by  careful 
palpation  and  percussion.  The  history  of  pain  (pointing  to  attacks 
of  local  peritonitis)  and  any  previous  tappings,  together  with  the  size 
and  duration  of  the  tumor,  will  also  help  in  deciding  as  to  adhesions. 
But  it  is  often  impossible,  before  the  abdomen  is  opened,  to  say 
whether  the  operation  will  be  easy  or  no. 

Date  of  Operation. — If  the  patient  defers  this,  she  should  be  warned 
of  the  importance  of  an  early  one.  The  certainty  of  increasing  ad- 
hesions and  difficulty,  the  greater  annoyance  of  the  tumor  (especially 
iri  unmarried  women),  the  attacks  of  peritonitis  with  their  pain,  the 
risk  of  twisted  pedicle  and  its  results,  must  all  be  remembered.  The 
patient  must  decide  between  living  a  year  or  two  with  the  above  risks 
before  her  and  the  growing  misery  of  the  tumor,  and  submitting  to 
an  operation  the  risks  of  which  are  but  small,  nowadays,  in  an 
average  case  which  is  taken  early. 

The  condition  of  the  viscera,  kidneys,  lungs,  etc.,  the  habits  of  the  pa- 
tient, her  amenability,  her  digestive  poivers,  must  all  be  considered. 

The  amount  of  skill  of  the  surgeon,  though  a  delicate  matter,  must  not 
be  left  without  mention.  No  one  should  operate  on  these  cases  who 
has  not  had  good  opportunities  of  seeing  others  operate  frequently, 
and  no  one  should  undertake  a  case  whose  ovariotomies  are,  at  the 
most,  likely  to  be  but  two  or  three  in  his  lifetime. 

Preparation  of  the  Patient. — For  a  week  before,  the  patient 
should  be  kej^t  quiet,  have  a  gentle  aperient  every  other  night,  and  a 
bath  once  in  the  twenty- four  hours.  The  solids  of  the  diet  should  be 
somewhat  restricted,  and  all  the  food  taken  easily  digested  and 
nutritious.  Sufficient  fluids  should  be  given  to  ensure  a  healthy 
clearing  out  of  the  kidneys,  a  little  sound  spirit,  well  diluted,  being 
as  suitable  as  any  stimulant.  If  needful,  one  of  the  salts  of  lithia 
may  be  given  three  times  a  day.  On  the  morning  of  the  operation 
an  enema  should  be  given,  a  light  breakfast  taken  early,  and  some 
good  beef- tea  or  soup  about  11  if  the  operation  takes  place  about  2 
P.M.  When  the  patient,  warmly  clad,  especially  as  to  her  extremities, 
comes  in  to  take  the  anesthetic,  only  two  or  three  faces  that  are 
familiar  to  her  should  be  present.  It  is  best  to  begin  with  chloro- 
form, but  ether  should  always  be  at  hand  to  go  on  with,  save  in  those 
cases  where  the  condition  of  the  lungs  is  against  this  course.  When 
the  patient  is  under  the  anaesthetic,  a  catheter  should  always  be 
passed,  but  not  by  the  operator  or  any  of  his  immediate  assistants. 


OVARIOTOMY. 


715 


Preparation  of  Instruments,  etc.— The  room,  which  has  been 
thoroughly  cleansed  and  not  rendered  too  comfortless  for  the  sake  of 
ventilation,  etc.,  should  have  a  temperature  of  about  65°.  A  good 
light,  and  one  likely  to  last,  should  be  secured.  The  table  should  be 
sufficiently  high  to  save  the  operator  stooping,  and  only  just  wide 
enough  to  hold  the  patient  comfortably.  A  dozen  new  Turkey 
sponges,  chosen  for  their  even  softness  of  texture,  should  be  thus  pre- 
pared :*  All  the  sand  is  got  out  of  them  by  beating  them  over  a 
sheet  or  a  towel,  a  process  which  requires  to  be  repeated  again  and 
again  by  trusty  hands.  When  they  are  really  sandless,  they  should 
be  placed  in  carbolic  acid  solution  (1  in  20,  and  to  be  kept  renewed), 
and  in  a  solution  of  1  in  40  for  a  few  hours  before  the  operation. 
During  this  they  should  be  cleansed  in  a  solution  of  the  same  strength. 
One  or  two  flat  ones  should  be  provided,  not,  as  is  often  the  case,  too 
large.  A  few  small  sponges  fit  for  use  on  holders  should  be  provided, 
to  leave  no  excuse  for  the  dividing  of  sponges  during  the  operation,  a 
course  to  be  unhesitatingly  condemned.  The  number  of  the  sponges 
should  be  accurately  known. 

The  following  should  be  in  readiness  :  Two  scalpels ;  blunt-pointed 
bistoury  ;  steel  director  ;  Key's  director ;  at  least  six  pairs  of  Spencer 
Wells'  forceps  ;  omentum  clamp-forceps  ;  cyst-forceps;  Spencer  Wells' 
vulsellum-trocarf  and  tubing ;  blunt-pointed  scissors ;  needles,  both 
twelve  straight,  two  being  threaded  on  each  suture  of  stout  silk  for 
closing  the  abdominal  wound,  and  fine  ones,  both  straight  and 
curved,  for  underrunning  any  bleeding  point  or  introducing  fine 
sutures  if  any  of  the  contents  of  the  abdomen  are  unavoidably  in- 
jured ;  two  aneurism-needles  ;  plenty  of  silk  and  chromic-gut  ligatures 
of  varying  sizes,  and  the  material  carefully  prepared,  including  some 
stout  enough  for  the  pedicle ;  two  pairs  of  dissecting-forceps ;  a  probe ; 
dressing-forceps ;  drainage-tubes,  both  glass  and  rubber ;  Paquelin's 
cautery ;  some  solid  perchloride  of  iron ;  abundance  of  carbolic  and 
boracic  acid  lotion;  a  foot-panto  stand  under  the  table;  another  to 
wash  the  sponges  in  ;  a  carbolic  spray ;  a  laryngeal  mirror.  The  in- 
struments should  stand,  in  two  trays  or  pie-dishes,  by  the  window  close 
to  the  operator's  right  hand ;  the  ligatures  and  sutures  should  be  in 
separate  porringers,  all  covered  with  carbolic  acid  (1  in  40). 

In  addition  to  the  anaesthetist,  three  assistants  should  be  present — 
one  to  tie  off  vessels,  etc.,  as  they  are  taken  up,  help  with  the  tumor, 

*  Mr.  Doran  {Ann.  of  Surg.,  May,  1888),  in  a  very  practical  paper  on  "The  Details 
of  Ovariotomy,"  points  out  that,  if  the  sponges  are  whitened  as  well  as  cleaned  in  a 
solution  of  siilphnrons  acid  (1  in  5  of  water),  they  will  readily  show  any  foreign 
matter  clinging  to  them.  He  advises  that  a  sponge  be  kept  in  Douglas'  pouch  during 
the  operation. 

t  One  or  two  smaller  trocars  should  also  be  in  readiness. 


716  OPERATIONS    ON    THE    ABDOMEN. 

etc.,  another  to  keep  the  edges  of  the  wound  over  the  intestines  if 
needful,  and  a  tliird  to  hand  instruments.  Two  nurses  should  be  at 
hand  to  cleanse  the  sponges.  Within  reach  of  the  operator  should  be 
a  porringer  of  carbolic  acid  (1  in  60)  for  him  to  dip  his  fingers  in 
occasionally.  The  abdomen  of  the  patient  should  be  shaved  and 
cleansed  (p.  581)  just  before  the  operation  ;  mackintoshes  are  care- 
fully packed  around  so  as  to  cover  all  save  the  field  of  the  operation, 
or  the  mackintosh  with  the  oval  opening  bound  with  adhesive  plaster 
may  be  used.* 

The  Operation. — An  incision,!  reaching  from  just  below  the 
umbilicus  to  within  2  inches  of  the  pubes,  is  made  in  the  linea  alba;}; 
rapidly  down  to  the  peritoneum.  Before  this  is  incised,  Spencer 
Wells'  forceps  are  applied  to  every  bleeding  point,  and  tied  off",  if 
needful,§  with  fine  chromic  gut.  The  peritoneum,  readily  recognized, 
when  healthy,  by  its  delicate  fasciculation  and  translucency,  is  care- 
fully hooked  up  so  as  to  take  up  nothing  else,  and  opened.  Occa- 
sionally large  veins  lie  superficial  to  it,  just  in  the  operator's  Avay. 
All  bleeding  must  be  arrested,  especially  at  the  lower  angle  of  the 
wound.  The  peritoneum  is  next  slit  up  on  two  fingers,  to  the  length 
of  the  incision,  and  the  pearly  glistening  cyst  comes  into  view.  The 
above  applies  to  an  easy  case  without  parietal  adhesions.  But  if  the 
peritoneum  is  thickened  and  adherent  to  the  cyst,  there  may  be  the 
greatest  difficulty  in  deciding  when  this  is  reached.  The  best  way  to 
solve  the  doubt  is  to  prolong  the  incision  upwards  to  the  left  of  the 
umbilicus,  till  a  spot  free  from  adhesions  is  found.  While  the  oper- 
ator is  in  uncertainty,  on  no  account  are  apparent  adhesions  to  be 

*  The  value  of  the  spray  is  not  finally  settled.  It  renders  the  operation  safer  in 
large  hospitals,  and  it  is  said  to  make  efTiisions  more  harmless,  and  thns  to  diminish 
the  need  of  drainage.  On  this  point  I  have  still  grave  doubts;  the  power  of  carbolic 
acid  to  render  discharges  innocuous  is,  I  tliink,  more  than  counterbalanced  in  ab- 
dominal surgery  by  its  tendency  to  cause  effusions  of  sero-sanguineous  fluid  during 
the  first  few  hours  after  an  operation.  Its  use  should  be  certainly  combined  with 
extra  carefulness  in  the  "  toilet."  Finally,  no  amount  of  attention  to  antiseptic  details 
will  replace  personal  experience,  fertility  in  expedients,  and  resourcefulness  in 
meeting  difficulties. 

t  This  should  be  from  2  to  3  inches  long  at  first.  Mr.  Doran  {loc.  supra  cit.)  thinks 
a  mistake  is  often  made  in  not  bringing  the  incision  near  enough  to  the  pubes,  which 
may  cause  much  trouble  when  the  pedicle  has  to  be  drawn  out,  and  greatly  impede  a 
thorough  exploration  of  the  pelvis.  With  regard  to  wounding  the  bladder,  the 
operator  should  trust  neither  to  the  position  of  the  lower  end  of  the  wound,  nor  even 
to  the  catheter,  but  solely  to  the  appearance  of  structures  exposed. 

X  If  the  linea  alba  is  missed  and  the  rectus  or  pyramidalis  cut  into,  the  middle  line 
will  be  found  by  pushing  a  probe  inwards  under  or  through  these  muscles. 

^  Forcipressure  should  be  trusted  to  as  much  as  possible,  the  forceps  being  left  on 
for  five  or  ten  minutes.  Many  ligatures  weaken  the  cicatrix,  and  may  cause  actual 
suppuration. 


OVARIOTOMY.  717 

separated,  or  the  parietal  peritoneum  may  be  detached  from  the  ab- 
dominal wall.  When  the  cyst  is  reached,  it  is  examined  with  two  or 
three  fingers,  wdiich  will  give  some  information  as  to  visceral  and 
posterior  adhesions.  As  soon  as  the  cyst-surface  is  really  made  out 
it  is  best  to  tap  it.  To  separate  the  adhesions  before  tapping  it  is,  in 
Mr.  Thornton's*  words,  "bad  practice,  because,  if  they  are  separated 
w^hile  the  parietes  and  cyst-wall  are  both  stretched  by  the  fluid,  all 
the  little  vessels  in  them  bleed,  and  very  serious  haemorrhage  may 
occur  out  of  sight  during  the  subsequent  emptying  of  the  cyst; 
whereas,  if  the  cyst  be  first  tapped,  the  contraction  of  both  parietes 
and  cyst-wall  closes  the  smaller  vessels." 

The  cyst  is  tappedf  by  carefully  plunging  in  a  Spencer  Wells'  trocar, 
then  guarding  the  point  with  the  inner  tube,  and  attaching  the  claAvs  to 
the  cyst  so  as  to  keep  this  on  the  trocar  as  forward  traction  is  made. 
If  it  is  clear  from  the  bulk  of  the  cyst  remaining  unaffected  that  it  is 
multilocular;;;  or  solid,  the  surgeon  must  reduce  it  before  attempting 
to  extract  it.  If  it  be  multilocular,  it  must  be  tapped  again  in  two  or 
three  more  places,  by  removing  the  trocar,  and  closing  the  puncture 
with  cyst-forceps,  and  then,  while  the  cyst  is  dragged  forwards  and 
steadied,  the  first  trocar  or  a  smaller  one  is  thrust  in  at  other  spots 
where  fluid' is  still  present.  This  is  better  practice  than  thrusting  the 
trocar  from  the  first  puncture  into  other  parts  of  the  cyst  in  the  dark. 
If  the  bulk  of  the  cyst  be  solid,  the  trocar  puncture  being  enlarged, 
and  clamp-forceps  firmly  keeping  forwards  the  edges,  the  surgeon  first 
introduces  two  or  three,  then  perhaps  all  the  fingers  of  one  hand,  and 
scoops  out  the  solid  material  till  the  bulk  of  the  cyst  is  sufficiently 
reduced  to  come  through  his  incision.  During  the  tapping  one  or  two 
sponges  must  be  kept  under  the  trocar  to  prevent  leakage  into  the 
peritoneal  cavity. 

If  the  wound  requires  enlargement,  this  is  best  done  with  a  blunt- 
pointed,  straight  bistoury,  and  the  use  of  two  fingers  as  a  director,  the 
incision  being  carried  to  the  left  of  the  umbilicus  so  as  to  avoid  any 
still  open  vessel  in  the  round  ligament.  As  the  cyst  comes  forward 
any  adhesions  must  be  dealt  with.  The  commonest  are  to  the 
omentum,  the  small  intestine,  and  transverse  colon.  The  separation 
must  be  effected,  bit  by  bit,  with  the  finger-nail  or  steel  director,  each 
bleeding  point  being  caught  with  pressure-forceps  and  tied.  Another 
method  is  to  underrun  bleeding  points,  especially  any  obstinate  ones 
in  the  perietal  peritoneum.    Any  persistent  oozing  may  be  touched 

*  Diet,  of  Surg.,  loc.  infra  cit. 

f  Great  care  must  be  taken  to  ensure  all  the  fluid  escaping  well  away  from  the 
wound,  and  with  sponges  under  tiie  trocar,  and  by  turning  the  patient  on  her  side,  to 
prevent  any  contamination  of  the  peritoneal  cavity. 

J  If  the  cyst  is  multilocular,  the  largest  should  be  first  chosen  (Gahibin). 


718  OPERATIONS  ON  THE  ABDOMEN. 

with  Paquelin's  cautery  or  the  iron  perchloride.  Mr.  Thornton  thus 
advises  the  use  of  the  hitter  :  "  The  surfaces  to  be  touched  shoukl  be 
dried  with  a  sponge;  then  a  small  sponge,  well  wrung,  should  be 
smeared  lightly  with  the  solid  perchloride,  and  firmly  pressed  against 
the  bleeding  surface  till  the  oozing  stops ;  a  large  flat  sponge  should 
be  spread  under  the  surfaces  thus  treated,  to  prevent  any  of  the  acid 
serum,  which  runs  away  immediately  after  the  application  of  the 
iron,  getting  on  to  the  intestines.  Oozing  surfaces  in  the  pelvis  are 
treated  in  the  same  way,  the  intestines  being  first  drawn  out  of  the  way 
and  protected  by  sponges." 

While  adhesions*  are  being  dealt  with,  tlie  sides  of  the  wound  must 
be  kept  well  approximated  by  an  assistant,  and  a  sponge  placed  in  the 
lower  angle  to  prevent  fluid  entering  here.  As  the  cyst  comes  forward, 
its  posterior  surface  will  either  be  free  or  attached  to  the  small  intestine. 
In  either  case  the  projection  of  any  coils  must  be  prevented  by  the  use 
of  a  large  flat  sponge  wrung  out  of  carbolic  acid  (1  in  40),  green  pro- 
tective, or  a  clean  towel  cut  in  two  and  soaked  for  half  an  hour  in  the 
above  solution  of  carbolic  acid. 

When  the  cyst  has  been  sufflciently  brought  outside,  the  pedicle  is 
dealt  with.  The  intra-peritoneal  method  is  now  almost  universally 
adopted.f 

The  centre  of  the  pedicle  being  found  by  unfolding  it,  an  aneurism- 

*  Sometimes  these  are  so  broad  as  to  require  separation  bit  by  bit,  and  the  applica- 
tion of  a  pressure-forceps  to  each  bleeding  point. 

t  Mr.  K.  Thornton  (Did.  of  Surg.,  vol.  ii.  p.  155)  thus  describes  the  method  of 
enucleation  for  cases  with  no  pedicle:  "Cases  are  met  with  in  which  the  base  of  the 
tumor  is  so  situated  between  the  layers  of  the  broad  ligament,  or  so  pushes  its  way 
under  the  peritoneal  covering  of  the  uterus,  or  of  the  pelvic  floor,  tliat  cautery  and 
ligatures  are  alike  inapplicable,  or,  at  least,  ligatures  can  only  be  applied  after  much 
previous  enucleation.  When  this  is  the  case,  an  incision  should  be  made  through  the 
peritoneal  capsule  of  the  tumor,  and  careful  enucleation  practiced  with  the  fingers.  It 
is  well,  if  possible,  so  to  direct  this  process  as  to  isolate,  at  an  early  stage,  the  parts  of 
the  broad  ligament  which  would  form  the  pedicle  in  an  ordinary  case,  and  then  to 
transfix  and  tie  them  in  the  usual  way.  After  this,  the  chief  blood-supply  of  the  tumor 
is  under  control,  and  the  rest  of  the  enucleation  may  be  more  rapidly  and  boldly  made. 
Shreds  of  capsule  which  bleed  should  all  be  secured  in  pressure-forceps,  and  ligatured 
with  or  without  transfixion  after  the  tumor  is  completely  shelled  out.  Usually,  the 
capsule  falls  together  and  no  oozing  occurs,  but  sometimes  this  is  troublesome  from  a 
large  surface,  and  Paquelin's  cautery  or  the  solid  perchloride  of  iron  may  be  applied 

[vide  supra~\ In  performing  these  enucleations,  the  operator  must  always  bear 

in  mind  the  fact  that  the  capsule  is  often  the  pelvic  parietal  peritoneum,  and  that  he 
is  consequently  brought  into  dangerously  close  relations  with  bladder  and  ureters, 
rectum  and  sigmoid  flexure,  or  caecum  and  appendix  (the  latter  is  very  frequently  ad- 
herent in  these  cases),  and,  as  it  bleeds  very  much  when  torn,  requires  careful  handling 
and  often  repair  with  a  fine  needle  and  silk.  The  large  iliac  vessels  are  also  occasion- 
ally incorporated  with  the  capsule." 


OVARIOTOMY.  719 

needle  loaded  with  stout  silk  (No.  1)  is  made  to  perforate  it  here  at  a 
spot  devoid  of  vessels.  The  loop  of  silk  being  drawn  through  and  the 
needle  withdrawn,  the  loop  is  cut,  and  the  two  ligatures  tied  firmly 
round  the  two  halves  of  the  pedicle.  To  make  the  silk  hold,  it  is  well 
to  loop  the  ligatures  round  some  blunt  instruments,  so  as  to  tie  them 
with  sufficient  force.  When  they  are  both  tied,  one  is  cut  short,  while 
the  other  is  thrown  round  the  whole  pedicle  and  tied  again.  The  cyst 
is  then  cut  away  not  more  than  f  inch,  and  not  less  than  i  inch  from 
the  ligatures.  When  this  is  done,  the  cut  end  is  carefully  examined, 
and  anj^  point  that  oozes  tied  with  fine  silk  or  chromic  gut.  The 
pedicle  is  then  allowed  to  drop  in,  and  the  finger,  following  it  down  to 
the  uterus,  finds  and  hooks  up  the  other  ovary.  If  this  is  found  en- 
larged, it  must  be  removed. 

The  operator  now  scrutinizes  the  parts  carefully,  removes  any  jagged 
omentum,  arrests  any  still  bleeding  points,  and  removes  any  sponges 
wdiieli  he  may  have  inserted,  and  has  them  all  counted. 

The  next  step  is  the  so-called  "  toilet,"  to  sponge  out  most  thoroughly 
the  pelvis,  the  spaces  in  front  of  and  behind  the  uterus,  and  those  on 
either  side  of  the  vertebral  column.  This  is  effected  by  introducing 
again  and  again  warm  sponges,  well  wrung  out,  on  clamp-forceps, 
until  they  I'eturn  dry  and  colorless. 

A  flat  sponge  being  now  introduced  to  catch  any  blood,  the  abdomi- 
nal wound  is  closed  by  means  of  sutures  of  stout  silk  with  a  needle 
at  either  end.  Each  needle  is  passed  from  within  outwards  through 
the  peritoneum  first,  and  then  through  the  skin,  at  least  k  inch  from 
the  edges  of  the  wound.*  The  sutures  are  inserted  about  J  inch  from 
each  other,  and  a  few  of  horsehair  may  be  put  in  quite  sujoerficially 
as  well.  Before  they  aie  tightened,  the  flat  sponge  is  withdrawn. 
When  they  are  all  tied,  a  little  iodoform  is  dusted  on,  the  abdomen 
cleansed,  and  dry-gauze  dressings  (sal  alembroth  or  iodoform)  applied. 

The  question  of  drainagef  must  depend  mainl}^  upon  the  complete- 
ness of  the  "toilet"  of  the  peritoneum,  the  probability  of  any  sub- 
sequent oozing,  especially  if  deep  in  the  pelvis,  and  the  possibility  of 
any  septic  fluid  having  entered  the  peritoneal  cavit3\  A  Keith's  glass 
tube  should  be  the  one  used,  one  end  resting  at  the  bottom  of  Douglas 
pouch  without  pressing  on  the  rectum,  the  other  passes  through  a  thin 
sheet  of  india-rubber,  its  neck  being  gripped  firmly  by  a  button-hole 
in  this.  Sponges  changed  frequently  are  jjlaced  over  and  around  this 
end  of  the  tube. 


*  They  slionld  not  be  tied  too  tightly,  else  points  of  suppuration  will  result. 

t  Mr.  Greig  Smith's  words  should  be  remembered:  "  The  question  of  drainage  is  a 
very  difficult  one  to  speak  about  in  theory.  In  practice,  a  good  rule  to  follow  is — 
'  When  in  doubt,  drain.'  " 


720  OPERATIONS  ON  THE  ABDOMEN. 

Accidents  during  Ovariotomy. 

1.  Fainting.  This  will  l^c  best  met  by  preventive  treatment.  If  it 
occur  during  the  operation,  ether  must  be  given,  the  head  lowered  and 
kept  warm,  and  subcutaneous  injections  of  brandy  given. 

2.  Vomiting.  This  chiefly  harasses  by  straining  the  intestines  out 
of  the  abdomen.  If  prolonged,  the  operation  must  be  completed  as 
soon  as  possible,  an  assistant  keeping  the  abdominal  walls  pressed 
against  the  viscera,  or  dragging  the  former  forward  after  pulling  them 
between  his  finger  and  thumb. 

8.  Separation  of  the  i:)arietal  peritoneum.  This  has  already  been 
spoken  of,  p.  717. 

4.  Rupture  of  the  cyst.  This  accident  may  be  expected  when  the 
walls  are  thin,  rotten,  or  softened  by  recent  peritonitis.  In  such  cases 
careful  handling,  keeping  suspicious  spots  well  out  of  the  wound  or 
packed  around  with  sponges,  and  additional  caru  with  the  "  toilet "  if 
any  fluid  has  got  into  the  peritoneal  cavity,  are  indicated. 

5.  Injury  to  viscera.  Of  these  the  bladder,  small  intestine,  rectum, 
and  ureter  are  most  likely  to  suffer.  In  the  case  of  the  bladder,  the 
surgeon  must  decide,  by  the  time  of  the  injury  and  the  amount  of 
damage,  as  to  whether  he  will  complete  the  operation  after  closing 
the  wound,  or  defer  it.  In  the  case  of  injury  to  the  intestine  the 
directions  given  at  pp.  665,  671  will  be  found  useful.  In  the  case  of 
the  ureter,  it  will  usually  be  wisest  to  ligature  the  lower  end,  if  possible, 
bring  the  upper  out  of  the  wound,  and  to  perform  nephrectomy 
subsequently,  as  in  Simon's  case, 

6.  Leaving  in  instruments — e.g,,  sponge  or  forceps.  The  fact  that 
this  accident  has  occurred  with  operators  of  the  largest  experience 
should  make  all  careful.  It  is  best  met  by  having  a  sufficient,  definite 
number  to  begin  with,  counting  carefull}^  afterwards,  and  allowing  no 
tearing  of  sponges. 

After-treatment. — I  have  no  space  for  going  carefully  into  de- 
tails, but  I  should  like  to  take  this  opportunity  of  saying  that,  critical 
as  the  first  forty-eight  hours  undoubtedly  are,  I  believe  there  is  often 
needless  enforcing  of  rules.  Less  should  be  done  in  the  way  of  fre- 
quent catheterism,*  the  amount  of  urine  being  now  small,  and  less 
routine  in  the  matter  of  morphia  if  the  patient  is  not  restless  or  wake- 
ful, and  less  rigor  in  enforcing  a  dorsal  position.  During  the  above 
time  little  should  be  given  by  the  mouth  save  cracked  ice,  and  occa- 
sional teaspoonfuls  of  barley-water,  or  Valentine's  meat-juice,  with  a 
few  drops  of  brandy  if  required,     Mr,  K.  Thornton  advises  the  fol- 

*  On  the  whole  I  prefer  a  metal  catheter  with  a  single  large  eye.  This  can  be  kept 
in  dilute  carbolic  acid,  and,  being  shorter  than  a  gum-elastic,  there  is  less  danger  of  its 
being  pressed  too  far  and  thus  causing  irritation  and  most  vexatious  cystitis. 


REMOVAL   OF    THE    UTERINE    APPENDAGES.  721 

lowing  enemata :  About  six  hours  after  the  operation,  or  sooner  if  the 
patient  be  very  weak,  3  ozs.  of  strong  beef-tea,  just  warm,  and  without 
salt,  are  injected  into  the  rectum.  This  is  to  be  repeated  every  three  hours 
(every  two  if  the  patient  is  very  weak),  and  every  six  hours  twenty 
drops  of  laudanum  are  added.  Before  each  injection,  the  female  pipe 
of  a  Higgenson's  syringe  is  placed  in  the  rectum,  with  the  bottom  of 
an  ordinary  soap-dish  under  it,  so  that  the  flatus  and  refuse  may  pass 
away;  it  remains  in  ten  minutes,  and  then  the  fresh  injection  is  given. 
The  chief  questions  that  arise  are,  how  best  to  act  in  threatening  or 
actual  peritonitis.  Where  only  flatulence  and  some  distension  are 
present,  they  may  yield  to  the  passage  of  a  long  rectal  tube,  and  the 
injection  of  a  pint  of  water,  with  or  without  turpentine.  These  fail- 
ing, relief  may  still  be  given  by  the  passage  of  a  stomach-tube ;  and, 
if  the  vomiting  and  tympanites  continue,  oj^ening  the  wound  below 
and  irrigation  of  the  peritoneal  cavity  with  2  per  cent,  of  warm  boracic 
acid  lotion  should  be  tried. 

REMOVAL  OF  THE  UTERINE  APPENDAGES.^^ 

Indications. — Before  giving  these,  I  would  state  that  there  is  no 
operation  in  which  it  is  more  necessary  to  consider  each  case  on  its 
own  bearings,  to  explain  the  object  and  results  with  honorable  care- 
fulness to  the  friends  and,  whenever  possible,  to  the  patient  herself, 
and  to  remember  that  this  is  above  all  one  of  those  operations  w^hich 
should  never  be  entertained  if  there  are  any  honest  doubts  as  to  the 
patient's  health  being  really  impaired  beyond  the  aid  of  other  treat- 
ment, and  the  impossibility  of  otherwise  restoring  her  to  usefulness  in 
the  position  in  life  in  which  she  has  been  placed. 

The  following  classification  of  possible  indications  for  the  operation 
(always  subject  to  the  above  remarks)  I  have  taken  from  Mr.  Greig 
Smith.t  His  detailed  consideration  of  each  of  them  will  well  repay 
study. 

"A.  The  Appendages. 
"  (1)  The  ovaries  : 

(a)  Inflammation — acute,  chronic,  and  suppurative  (abscess). 
(6)  Displacement  (prolapse,  hernia), 
(c)  Cirrhotic  and  cystic  ovaries. 
"  (2)  The  Fallopian  tubes  : 

(a)  Inflammation ;  salpingitis. 
(6)  Pyo-salpinx. 
(c)  Hfemato-salpinx. 

*  This  term  has  been  used  liere  for  convenience'  sake,  as  more  comprehensive  than 
"  oophorectomy,"  etc.  Moreover,  it  is  as  yet  not  certain  whetiier  removal  of  the 
ovaries  withont  the  Fallopian  tube  will  be  sufficient  to  arrest  menstruation. 

t  Loc.  supra  cit,,  p.  152. 

46 


722  OPERATIONS  ON  THE  ABDOMEN. 

(d)  Hydro-salpinx, 

(e)  Fallopian  pregnancy. 
"  B.  The  Uterus. 

(a)  Uterine  myoma.* 

(6)  Errors  of  development — absence  or  mal-developmcnt  of  uterus 
with  menstrual  m oilmen. 

(c)  Incurable  displacements  with  severe  nerve  symptoms. 

(d)  Insuperable  obstruction  to  menstrual  flow  (may  reside  in 

vagina). 
"  C.  The  Nervous  System. 

(a)  Mania,  puerperal  mania,  menstro-mania,  nympho-mania,  etc. 

(b)  Epilepsy,  hystero-epilepsy,  convulsions,  cramps,  dancing  fits, 

etc. 

(c)  Hysteria.f 

Operation. — It  will  be  more  useful  to  my  readers  if  I  quote  here 
from  one  who  has  had  more  experience  of  this  operation  than  myself.J 

"TFAen  the  Apjiendages  are  Anatomically  Normal,  or  nearly  so. — The 
incision,  made  in  the  ordinary  median  position,  need  not  be  longer 
than  1^  or  2  inches — enough  to  admit  two  fingers  easily.  As  the  pari- 
etes  are  not  thinned  and  distended  by  a  tumor,  the  linea  alba  is  very 
narrow,  and  it  is  not  often  that  it  can  be  divided  without  exposing 
one  or  both  recti.  A  small  opening  is  made  in  the  fascia  ;  if  it  is  in  the 
linea  alba,  well  and  good  ;  if  not,§  the  layers  are  pushed  to  one  side  or 
the  other,  and,  Avhen  the  situation  of  the  fibrous  septum  is  found,  the 
fascia  is  slit  up  to  the  length  of  the  wound  by  the  point  of  the  knife 
cutting  forwards.  The  muscular  fibres  are  pushed  to  one  side  with 
the  handle  of  the  scalpel,  and  the  sub-peritoneal  fat  exposed.  This 
is  caught  upon  two  catch-forceps,  and  carefully  divided  between  them. 
....  The  peritoneum  is  easily  recognized  ;  a  small  opening  is  made 
in  it  while  it  is  thus  everted ;  the  finger,  inserted  into  this  opening, 
acts  as  a  director  upon  which  the  division  is  completed,  preferably  by 
scissors.  By  this  method,  which  is  Tait's,  there  is  no  danger  of  wound- 
ing the  bowels ;  as  each  fold  of  tissue  is  pulled  up  and  made  tense,  it 
is  cut  on  its  folded  edge  by  the  knife  held  horizontally ;  and  when  the 

*  "  Those  varieties  of  fibroids  which  are  liable  to  continue  growing  after  the  meno- 
pause— that  is  to  say,  soft,  non-encapsiiled  fibroids,  and  fibro-cystic  tumors — are  likely 
also  to  be  unaffected  by  oopliorectomy  "  (Galabin,  Dis  of  Women,  p.  244). 

f  Many  will  demur  to  some  of  the  indications  given  under  this  heading.  With 
regard  to '' puerperal  mania,"  Mr.  Greig  Smith  thinks  that  the  operation  is  "  espe- 
cially indicated  if  the  disease  has  occurred  after  a  second  confinement."  With  regard 
to  "  hysteria,"  even  if  associated  with  "dancing  fits,"  all  will  agree  with  him  that 
"the  attacks  would  have  to  be  very  troublesome  indeed,  and  the  case  would  have  to  be 
surroimded  with  every  conceivable  inducement  to  operate,  before  interference  could 
be  contemplated." 

X  Greig  Smith,  loc.  supra  ciL,  p.  166.  §  P.  716. 


REMOVAL    OF   THE    UTERINE    APPENDAGES,  723 

veiy  smallest  opening  has  been  made  in  the  peritoneum  the  air  rushes 
in,  and  the  bowels,  if  they  have  been  dragged  forward  by  suction,  fall 
back  at  once 

"  The  two  first  fingers  are  now  inserted  into  the  wound.  If  omen- 
tum covers  the  bowels,  it  must  be  dragged  upwards ;  if  not,  the  fingers 
are  pushed  straight  down  to  the  fundus  uteri.  The  fingers,  one  on 
each  side  of  the  broad  ligament,  and  grasping  it  between  them,  are 
now  carried  outwards  till  the  ovary  is  felt;  it  is  then  lifted  out  of  the 
wound  with  its  mesovarium  and  oviduct.  Still  held  in  this  position 
with  the  left  hand,  the  Fallopian  tube  is  pulled  out  as  far  as  it  will 
readily  come,  and  the  pedicle  spread  out  for  ligature.  The  parts  to 
be  removed  are  the  ovary  with  its  mesovarium,  and  the  Fallopian 
tube  in  its  outer  three-fourths,  with  the  double  peritoneal  fold  in 
which  it  lies,  and  which  contains  also  the  parovarium  and  the  vascular 
erectile  tissue  known  as  the  bulb  of  the  ovary.  The  ligature  is  placed 
double  by  transfixing  with  a  blunt  needle.  The  inner  pedicle  con- 
tains the  utero-ovarian  ligament,  the  Fallopian  tube  somewhere  near 
its  isthmus,  the  spermatic  artery  and  veins,  and  the  small  branch 
which  accompanies  the  Fallopian  tube.  The  outer  ligature  lies  at  the 
retiring  angle  where  the  infundibulo-j^elvic  and  infundibulo-ovarian 
ligaments  meet,  takes  its  Iralf  of  the  mesovarium,  and  also  constricts 
the  spermatic  artery.     In  most  cases,  no  method  of  ligature  is,  in  my 

opinion,  superior  to  Tait's  Staffordshire  knot The  parts  are 

then  cut  away  bj^  successive  snips  of  scissors  at  a  distance  of  about  i 
inch  from  the  ligature.  Before  making  the  last  cut  the  surface  must 
be  carefully  inspected  to  see  that  there  is  no  bleeding.     The  pedicle  is 

then  dropped  in The  same  proceeding  is  then  carried  out  with 

the  appendages  on  the  opposite  side. 

"A  small,  thin,  flat  sponge  is  placed  over  the  bowels  under  the 
incision,  and  the  sutures,  four  or  five  in  number,  are  introduced. 

"TFAe/i  the  Appendages  are  Inflamed   and  Adherent. — The    previous 

operation  is  a  very  simple  one But  it  is  a  very  different  thing 

if  the  appendages  are  adherent  or  inflamed,  or  suppurating  or  matted 
together,  as  in  inflammatory  diseases.  Then  the  operation  may  be 
one  of  the  most  difficult  in  surgery.  Even  in  the  hands  of  surgeons 
of  the  highest  skill,  it  has  not  infrequently  been  abandoned  as  im- 
practicable. The  first  difficulty  met  with  is,  probably,  that  the 
ap23endages  are  fixed  and  cannot  be  drawn  to  the  surface.  They  may 
be  represented  by  an  irregular  conglomeration  of  cystic  and  cicatricial 
material,  and  sessile  on  the  broad  ligament  or  in  Douglas's  pouch,  and 
perhaps  intimately  adherent  to  bowels.  They  are  beyond  the  reach 
of  sight,  however  much  the  abdominal  walls  are  depressed.  To  deal 
with  such  a  state  of  affairs  one  of  two  courses  is  open.  The  first  is  to 
enlarge  the  incision  to  3  or  4  inches ;  to  pull  the  bowels  out  of  the 


724  OPERATIONS  ON  THE  ABDOMEN. 

pelvis,  and  keep  them  in  the  abdomen  by  one  or  more  sponges  packed 
under  them;  to  pull  the  parietes  apart  by  spatulae,  and  seek  by  a 
strong  light  to  expose  the  parts  to  view,  and  operate  by  the  aid  of 
light.  This  may  be  safe,  but  it  is  clumsy  and  difficult.  If  the  pari- 
etes are  muscular  and  firm,  considerable  force  may  be  required  to 
crowd  the  bowels  into  the  abdomen,  and  to  keep  them  there  is  still 

more  difficult Tiie  other  course  is  that  followed  b}'  Tait,  as  a 

result  of  his  unrivalled  experience.  Tait  has  come  to  the  conclusion 
that  it  is  best  to  depend  entirely  on  the  fingers  to  deal  with  such  a 
condition,  relying  on  the  skilled  sense  of  touch  to  guard  against  the 
dangers  of  tearing  bowels  or  other  structures.  To  control  bleeding  he 
recommends  sponge  packing.  Firstly,  the  fingers  map  out  the  actual 
limits  of  the  diseased  organs ;  then  these  are  gently  separated  from 
all  surrounding  parts,  and  gradually  the  mass  is  unfolded  upwards 
from  behind  till  the  only  attachment  left  is  the  proper  pedicle  of  the 
parts  to  be  removed.  Even  as  thus  separated,  the  appendages  will 
probably  be  found  sessile  on  the  broad  ligament,  so  that  they  can  be 
little  more  than  brought  within  the  range  of  sight.  The  broad  liga- 
ments are  stretched  tightly  across  the  pelvis,  and  dragging  on  the 
appendages  may  tear  them.  The  pedicle  ligature  may  have  to  be  car- 
ried under  the  diseased  parts  at  a  considerable  depth  from  the  surface. 
If  possible  the  tissues  are  gathered  together  in  one  pedicle,  or  by  the 
Staffordshire  knot;  but  the  puckering  produced  may  drag  upon  the 
opposite  ligament  so  much  as  to  cause  tearing.  To  tie  in  two  parts 
almost  of  necessity  tears  open  the  tissue  between  them.  It  has  hap- 
pened to  me  in  one  case,  while  pulling  on  a  ligature,  that  the  broad 
ligament  was  torn  clean  away  from  the  side  of  the  uterus  for  a  distance 
of  more  than  an  inch.*  .... 

''  The  bleeding  in  these  cases  is  sometimes  described  as  truly  alarm- 
ing, and  I  have  had  practical  experience  of  this  fact.  Sponges  are 
packed  in  everywhere  as  the  adhesions  are  separated.  If,  after  the 
appendages  have  been  removed,  bleeding  still  goes  on,  a  little  solution 
of  iodine  on  a  sponge  may  be  applied  to  the  raw  surfaces.  Of  course, 
visible  bleeding  points  are  dealt  with  by  ligature  or  foreipressure. 
And  it  may  sometimes  be  good  practice  to  leave  forceps  attached  to 
bleeding  points  for  twenty-four  hours  or  so,  their  handles  being  left 
outside.  In  all  such  cases  the  insertion  of  a  drainage-tube  for  a  day 
or  two  is  advisable. 

"  If  abscesses  exist,  extra  care  is  necessary  to  avoid  rupture  of  the 
abscess-wall.  It  may  be  wise,  before  beginning  separation,  to  aspirate 
the  contents,  and  place  a  pressure-forceps  on  the  opening  so  made. 

*  Mr.  Greig  Smith  (loc.  supra  cit.,  p.  170)  tliinks  that  an  india-rubber  bag  inflated 
in  the  rectum  might,  by  raising  the  pelvic  floor,  be  sometimes  of  use. 


ABDOMINAL    SECTION    FOR    MYOMATA.  725 

In  such  cases  the  placing  of  sponges  all  round  the  diseased  parts  is 
peculiarly  necessary. 

"  For  Uterine  Myoma. — For  small  myoniata  the  proceeding  may  be 
in  no  way  different  from  the  simplest  operation.  In  fact,  as  the 
appendages  are  raised  with  the  fundus,  and  the  broad  ligaments  are 
usually  soft  and  distensile,  the  operation  may  be  rendered  easier. 

"When  the  tumor  is  large,  and  especially  when  it  is  adhercHt,  the 
difficulties  may  be  great,  even  insuperable.  Not  a  few  such  opera- 
tions, begun  as  oophorectomy,  have  to  be  finished  as  hysterectomy. 
If  the  tumor  grows  away  from  the  uterus,  being  sub-peritoneal  and 
near  the  fundus,  the  appendages  may  be  deep  in  the  pelvis.  Where 
the  growth  lies  between  the  broad  ligaments  the  ovaries  will  be  elevated 
and  squeezed  between  the  tumor  and  the  parietes.  In  an  unsym- 
metrical  growth  one  ovary  may  be  quite  conveniently  near  the  surface, 
while  the  other  lies  out  of  reach  and  behind.  Indeed,  we  must  expect 
an  endless  variety  of  situation,  and  in  some  cases  be  prepared  not  to 
find  ovaries  at  all.* 

"  When  one  ovary  is  found,  we  must,  before  proceeding  to  remove 
it,  find  the  other ;  and  before  removing  one  we  must  be  certain  that  it 
is  possiole  to  remove  both.  Having  decided  to  remove  the  appendages, 
we  rotate  the  tumor  to  one  side  so  as  to  bring  the  parts  first  to  be 

removed  as  close  as  possible  to  the  surface Thornton's  plan  of 

not  cutting  off  the  first  ovary  till  all  manipulations  are  over  with  the 
second  is  a  good  one;  it  minimizes  the  risk  of  bleeding  from  the 
divided  pedicle." 


CHAPTER  XL 

OPERATIONS  ON  THE  UTERUS. 

REMOVAL  OF  MYOMATA  BY  ABDOMINAL  SECTION. 
—REMOVAL  OF  A  CANCEROUS  UTERUS  BY  AB- 
DOMINAL SECTION.— REMOVAL  OF  A  CANCEROUS 
UTERUS  PER  VAGINAM. 

REMOVAL  OF  MYOMATA  BY  ABDOMINAL  SECTION. 

Indications, — These  are  thus  laid  down  by  the  chief  authority  on 
this  subject,  Dr.  T.  Keith.f 

1.  In  very  large  rapidly  growing  tumors  of  all  kinds  in   young 

*  Prof.  Simpson  [Edin.  Med.  Joiirn.,  vol.  xxx.  p.  444)  has  practiced  with  benefit 
ligature  of  the  broad  ligaments  in  cases  vvliere  removal  of  the  appendages  has  been 
found  impossible. 

f  Hysterectomy  for  Fibrous  Tumors  of  the  Uterus. 


726  OPERATIONS  ON  THE  ABDOMEN. 

women.  By  a  large  tumor  is  meant  one  of  upwards  of  20  lbs.  2.  In 
all  cases  of  real  fibro-cystic  tumors,  if  tbey  can  be  removed ;  also  in 
all  cases  of  suppurating  tumors.  3.  In  most  cases  of  soft,  oedematous, 
fibrous  tumors.  These  often  grow  to  an  enormous  size,  far  larger  than 
any  ovarian  tumor.  4.  In  cases  of  large  bleeding  fibroids  of  any  age, 
provided  that  the  patient  is  not  approaching  fifty,  that  her  life  is  prac- 
tically useless,  and  that  further  exiDcrience  in  the  operation  shall  show 
that  the  mortality  of  hysterectomy  is  likely  to  diminish.  5.  In  certain 
cases  of  tumor  surrounded  by  free  fluid,  the  result  of  peritonitis,  pro- 
vided that  the  fluid  shows  a  tendency  to  re-accumulate  after  two  or 
three  punctures. 

Mr.  Greig  Smith  {Abdom.  Surg.,  p.  201)  adds  another — viz.,  where  an 
operation  with  a  view  of  removing  the  uterine  appendages  has  been 
found  impracticable,  and  examination  proves  that  the  myoma,  with 
or  without  the  uterus,  can  be  removed  ;  in  such  a  case  the  major 
operation  may  be  proceeded  with. 

Operation. — The  preparations,  etc.,  are  much  as  have  been  given 
for  ovariotomy  (p.  714),  but  the  following  instruments  will  be  wanted 
as  well — viz.,  two  clamps  of  Koeberle's  pattern,  or  Keith's  large  clamp, 
additional  large  clamp-forceps,  and  serre-noeud  pins. 

An  incision  is  made  in  the  linea  alba  from  the  umbilicus  downward 
so  as  to  admit  the  hand  and  examine  the  tumor.  If  it  is  decided  to 
proceed,  the  incision  is  prolonged  upward  to  the  left  of  the  umbilicus 
sufficiently  freely  to  allow  of  the  tumor  being  brought  out  without 
bruising  of  the  incision  or  undue  force.  Any  adhesions  to  the  parietes 
or  omentum,  intestines  or  stomach  being  dealt  with,  the  growth  is 
lifted  forwards  by  one  or  two  of  Tait's  screws.  This  is  often  rendered 
very  difficult  if  the  lower  part  of  the  growth  be  firmly  fixed  in  the 
pelvis.  As  it  comes  out  the  surgeon  must  take  care  that  he  is  not 
pulling  dangerously  on  viscera  behind  to  which  the  growth  may  still 
be  attached,  and  which  he  cannot  see.*  The  relation  of  the  bladder 
to  the  tumor  must  now  be  carefully  made  out.  If  the  growth  has 
extended  into  the  pelvis  or  between  the  layers  of  the  broad  ligament, 
its  connection  with  the  bladder  may  be  very  intimate.  Thus,  the 
relations  of  the  bladder  must  be  defined,  and,  if  needful,  the  two 
must  be  separated  by  careful  dissection,  a  stej)  made  easier  by  not 
emptying  the  bladder  before  the  operation. 

The  next  step  is  to  examine  into  the  condition  of  the  pedicle  and  to 
decide  how  to  treat  it.  Of  the  two  methods,  intra-  and  extra-perito- 
neal, the  former  is  now  rarely  used,  owing  to  the  risk  of  haemorrhage 
from  shrinking  of  the  uterine  tissue,  or  of  sloughing  and  septicaemia. 

*  Mr.  K.  Tliornto-n  {Diet,  of  Surg.,  vol.  ii.  p.  746)  points  out  that  ranch  more  care 
is  reqnired  in  securing  adliesions  now,  as  a  ^olid  tumor  allows  of  much  more  hsem- 
orrhage  than  a  collapsed  ovarian  cvst. 


ABDOMINAL,   SECTION    FOR    MYOMATA. 


727 


Extra- Peritoneal  Treatment  of  the  Pedicle. — The  following  are  the  cliief 
means  employed : 

1.  Wire  constriction  (Koeberle,  Tait).     (Fig.  118.) 

2.  Clamps  (Keith). 

3.  Forcipressure  and  ligature  of  vessels  (Spencer  Wells).   (Fig.  119.) 

4.  Elastic  ligature  (Martin  and  other  German  surgeons). 

5.  Enucleation. 

(1)    Wire  Constriction. — This  is  the  form  most  usually  employed. 
The  loop  is  adjusted  either  round  the  narrowest  part  of  the  attachment 


Fig.  118. 


Fio.  119. 


Temporary  forcipressure  in  the  removal  of  a  uterine 
tumor.    (Spencer  Wells.) 


Koeberle's  serre-nceud.    (Galabin.) 


of  the  tumor,  or,  if  it  be  needful  to  open  the  cavity  of  the  uterus,  just 
above  the  internal  os.  If  it  be  possible  to  include  the  appendages  in 
the  loop  this  is  done  ;  in  other  cases  the  broad  ligaments  must  be  tied 
sepai'ately  after  transfixion.  When  the  loop  is  tightened  in  position 
it  is  screwed  up  slowly,  for  tlie  shrinking  of  the  tissues  will  allow  of 
further  tightening  of  the  wire  later  on.     One  or  two  pedicle-pins  are 


728  OPERATIONS  ON  THE  ABDOMEN. 

now  thrust  through  the  tumor  just  above  the  loop,  it  being  intended 
that  the  broad  and  protected  ends  of  these  shall,  by  resting  on  the 
abdominal  walls,  keep  up  the  stump  in  position.  During  the  above 
steps  sponges  will  have  been  applied  so  as  to  stop  any  fluids  from 
going  into  the  peritoneal  cavity.  Fresh  ones  are  now  carefully  packed 
around,  and  the  growth  is  cut  away  sufficiently  beyond  the  pins  to 
allow  of  paring  down  a  little  later.  After  this  has  been  efifected,  the 
wire  is  finally  tightened.  The  stump  thus  pared  down  and  painted 
with  iron  perchloride  or  a  strong  solution  of  carbolic  acid,  and  dusted 
with  iodoform,  is  retained  in  situ  by  the  pins  and  by  the  first  of  the 
sutures  closing  the  abdominal  wall,  which  is  put  in  immediately  above 
the  stump. 

Any  oozing  points  are  now  finally  looked  to,  the  peritoneal  cavity 
cleansed,  and  the  rest  of  the  abdominal  wound  closed  with  the  pre- 
cautions given  at  p.  719.  Dry  gauze  strips  dusted  with  iodoform — 
these  being  distinct  from  those  over  the  rest  of  the  abdominal  wound 
— are  carefully  packed  around  the  stump,  and  some  are  placed  under 
the  ends  of  the  pins. 

The  wire  is  tightened  when  the  dressings  are  changed — about  every 
two  days — fresh  strips  and  the  iron  perchloride  being  applied  as  a 
little  of  the  stump  is  clipped  away.*  If  the  wire  has  not  made  its 
way  through  in  about  two  weeks  it  may  usually  be  divided  and 
removed  at  this  time. 

(2)  Clamp. — Dr.  Keith  uses  one  of  these  made  very  large  and  thin, 
as  likely  to  cause  less  sloughing  than  the  wire,  as  it  spreads  out  the 
pedicle  more.     The  stump  is  treated  in  the  same  way  as  above  given. 

(3)  Forcij)ressure  and  Ligature  of  Vessels. — This  mode  of  making 
temporary  compression  has  been  employed  by  Sir  S.  Wells  with  his 
powerful  forceps.  "  Temporarily  compressing  the  neck  by  two  pairs 
of  large  forceps,  as  shoAvn  in  the  woodcut,  the  tumor  was  cut  away 
about  2  inch  above  the  forceps.  Transfixing  between  the  points  of 
the  two  forceps  with  a  large  needle  carrying  a  double  strong  silk 
ligature,  each  ligature  was  tightened  below  the  forceps,  and  as  the 
forceps  were  successively  removed  the  ligatures  were  still  further 
tightened  before  the  second  knot  was  made.  A  third  ligature  was 
then  applied  close  behind  the  other  two.  The  peritoneal  edges  of  the 
stump  were  then  brought  together  by  a  few  points  of  uninterrupted 
suture  of  fine  silk."     In  other  cases  Sir  Spencer  has  dispensed  with 


*  As  Ihis  process  is  repeated  great  care  must  be  taken  not  to  cut  into  tissues  which 
are  still  living.  The  tendency  of  the  pedicle  to  sink  back  into  a  cone-shaped  de- 
pression just  above  the  pubes  must  also  be  remembered,  the  adhesions  here  remaining 
for  some  time  very  weak,  and  daily  attention  being  required  to  keep  the  parts  in  a 
dried  aseptic  condition  with  iron  perchloride  and  iodoform. 


ABDOM[NAL   SECTION    FOR   CANCEROUS    UTERUS.  729 

ligatures,  takinu;  up  the  vessels  with  pressure-forceps  and  tying  them 
one  by  one  as  the  large  forceps  were  removed. 

(4)  Elastic  Ligature. — This  method  has  been  largely  used  by  Ger- 
man surgeons,  especially  Prof.  Hegar,  of  Berlin.  Dr.  Lee,*  of  Xew 
York,  thus  describes  its  application.  The  base  of  the  pedicle  is 
surrounded  "  as  low  down  as  possible  with  Kleeburg's  elastic  ligature, 
which  is  tied  while  on  the  stretch.  Above  this  a  double  ligature  is 
passed  through  the  stump,  tied  firml}^  in  two  sections,  and  all  above 
that  cut  away.  Now,  drawing  up  this  stump  into  the  lower  angle  of 
the  abdominal  wound,  the  parietal  peritoneum  is  stitched  securely  to 
the  peritoneal  covering  of  the  pedicle,  just  below  the  elastic  ligature. 
The  first  suture  above  the  stump  is  passed  through  the  parietal  peri- 
toneum, then  under  the  elastic  ligature  and  through  the  peritoneum 
on  the  opposite  side ;  when  this  is  tightened  it  closes  in  the  stump 
with  peritoneum  completely.  Two  more  sutures  are  passed  first 
above  this  through  the  peritoneum  only,  and  the  rest  of  the  wound  is 

closed  as  usual About   the  tenth  day  the  elastic  ligature  is 

carefully  cut  away,  and  good  union  is  obtained  in  a  fortnight. 

REMOVAL  OF  A  CANCEROUS  UTERUS  BY  ABDOMI- 
NAL SECTION. 

This  operation,  introduced  by  Freund  of  Strasbourg,  has  been 
largely  abandoned  on  account  of  its  fatality.  It  is  contrasted  with 
the  vaginal,  and  the  indications  are  given  later  on,  p.  733. 

Operation. — The  abdomen  being  opened  iii  the  usual  way,  as 
close  down  to  the  sj^mphysis  pubis  as  is  safe,t  the  intestines  are  drawn 
out  of  the  pelvis  into  the  abdomen,  and  if  it  be  needful  to  get  more 
room,  are  brought  out  and  covered  with  carbolized  towels  kept  warm 
(p.  655).  The  uterus  is  now  caught  with  a  powerful  vulsellum,  and 
dragged  first  to  one  side  and  then  to  the  other,  while  the  broad  liga- 
ments are  transfixed  by  three  ligatures  which  are  made  to  interlock 
when  tied.  These  are  thus  described  by  Mr.  Thornton  {loc.  supra  cit.) : 
"  The  first  loop  passes  through  the  ovarian  ligament  and  edge  of  the 
peritoneal  covering  of  the  Fallopian  tube,  and  secures  the  ovarian 
vessels ;  the  second  loop  passes  through  the  round  ligament  and  se- 
cures the  pampiniform  plexus.  When  the  first  two  loops  have  been 
tied  on  each  side,  the  ovaries  and  tubes  are  cut  away,  and  the  uterus 
is  firmly  drawn  out  of  the  pelvis,  and  a  transverse  incision  is  made 
through  the  peritoneum  between  the  uterus  and  bladder;  the  latter  is 
then  peeled  back|  and  the  incision  carried  through  into  the  vagina. 

*  Intern.  Encycl.  of  Surg.,  vol.  vi.  p.  841. 

t  Dr.  Lee  advises  partial  detachment  of  the  recti  from  their  pubic  insertion  if  tlie 
abdominal  walls  are  very  tense. 

X  During  this  a  sound  may  be  kept  in  the  bladder. 


730  OPERATIONS  ON  THE  ABDOMEN. 

The  uterus  is  then  held  forwards,  and  the  peritoneum  divided  trans- 
versely behind  to  the  same  extent  as  in  front,  and  the  vagina  opened 
into  through  the  pouch  of  Douglas.  The  uterus  is  now  merely  held 
hy  small  portions  of  tissue  on  each  side,  which  contain  the  uterine 
arteries,  and  the  third  loop  of  the  broad  ligament  ligatures  is  passed 
through  on  each  side  into  the  vagina,  or  from  the  vagina  by  a  special 
curved  needle,  and  tied  round  the  tissues  containing  the  uterine 
arteries ;  these  small  bridges  of  tissue  on  each  side  are  then  cut 
through  and  the  uterus  removed."  Mr.  Thornton  recommends  that 
where  the  vagina  allows  of  it  the  uterus  should  be  drawn  out  here, 
as  less  likely  to  contaminate  the  peritoneum  and  cut  tissues  with 
cancerous  discharge  than  when  it  is  taken  out  of  the  abdominal 
incision.  Any  bleeding  points  are  now  secured,  a  large  T  drainage- 
tube  is  placed  in  the  w^ound  with  its  central  part  brought  out  through 
the  vagina.  The  edges  of  the  cut  peritoneum  are  then,  as  far  as 
possible,  united,  the  parts  finally  sponged  out,  and  a  little  iodoform 
dusted  in.  The  abdominal  wound  is  then  closed  in  the  usual  way. 
Prior  to  this  operation  the  vagina  must  have  been  carefully  cleansed 
by  the  precautions  given  below. 

REMOVAL  OF  A  CANCEROUS  UTERUS  PER  VAGINAM. 

Preparatory  Treaiment. — For  some  days  before  the  external  genitals 
are  thoroughly  cleansed,  the  vagina  washed  out  with  solution  of 
carbolic  acid  or  mercury  perchloride,  and  a  plug  of  iodoform  wool 
inserted.  If  any  very  foul  granulations  are  present,  strong  carbolic 
acid  may  be  applied  to  them.  The  bowels  are  also  thoroughly 
cleared  out. 

Operation. — The  patient  being  in  lithotomy  jDOsition,  supported  by 
Clover's  crutch,  the  uterus  is  strongly  dragged  down  with  a  vulsellum, 
sufficiently  powerful,  but  with  no  larger  handles  than  is  needful. 
The  parts  are  dilated  for  the  surgeon  by  an  assistant  with  a  duck-bill 
speculum  held  posteriorly,  by  another  dragging  over  the  uterus  as 
directed,  and  also  by  the  left  hand  of  the  operator.  With  scissors 
the  mucous  membrane  is  next  cut  through  circularly,  well  clear  of 
the  disease.  As  Mr.  Greig  Smith  remarks,  the  normal  relations  of  the 
uterus  to  the  bladder  and  rectum  have  been  altered.  The  rest  of  my 
account  is  quoted  from  the  above  surgeon  :  "  The  mucous  membrane 
is  now  elevated  from  the  cervix,  the  connecting  cellular  tissue  being 
divided  by  forefinger  and  scissors.  A  catch-forceps  placed  on  the 
anterior  flap  and  handed  to  the  assistant,  who  pulls  it  forward  while 
he  depresses  the  cervix  with  the  vulsellum,  Avill  facilitate  the  dissec- 
tion in  front,  while  a  reversed  manipulation  will  be  of  equal  advantage 
behind.  Laterally,  no  cutting  must  be  made  after  the  mucous  mem- 
brane is  divided.     The  cellular  tissue  must  be  pushed  up  as  high  as 


VAGINAL    EXTIRPATION    OF    A    CANCEROUS    UTERUS.  731 

possible  by  the  finger  without  tearing  it;  frequently  the  upward 
limit  will  be  defined  by  a  feeling  of  pulsation  in  the  uterine  arteries. 
....  When  the  mucous  membrane  has  been  cleared  from  the  cervix 
as  high  up  as  the  peritoneum,  that  membrane  is  perforated  in  front 
and  behind,  and  the  abdominal  cavity  is  entered.  The  forefinger  is 
the  best  perforator.  Above  the  internal  os,  the  peritoneum  is  closely 
adherent  to  the  uterus  anteriorly  and  posteriorly,  where  the  finger 
ma}'  be  pushed  through  it  by  a  little  judicious  manipulation.  If  it 
is  more  than  ordinarily  tough,  and  it  seems  to  be  yielding  and 
stretching  in  front  of  the  finger,  a  Lister's  sinus-forceps  sharplj' 
pushed  through  it  will,  after  separation  of  the  blades,  make  an  open- 
ing large  enough  to  admit  the  finger.  The  opening  is  enlarged  in 
front  and  behind  by  tearing  with  the  finger  on  both  sides  as  far  as 
the  broad  ligaments.  A  soft  sponge  is  now  pushed  through  into  the 
posterior  cul-de-sac  and  left  there.  It  serves  to  protect  the  bowels 
and  keep  them  out  of  the  way,  while  it  absorbs  any  fluids  and  lies 
between  the  general  cavity  and  any  i30ssible  infection  from  the 
cancerous  uterus." 

The  most  difficult  and  delicate  step  in  the  whole  proceeding  is  the 
separation  of  the  uterus  from  the  broad  ligaments,  and  the  securing 
of  its  vessels' against  bleeding.  Mr.  Greig  Smith,  having  alluded  to  the 
endless  variety  of  plans  devised  to  meet  this  difficulty,  thinks  that  the 
best  and  simplest  means  is  aff'orded  by  a  clamp  which  he  has  devised. 
It  is  a  straight  one  with  long  handles  and  grooved  laterally  so  as  to 
guide  a  small  knife  in  cutting  through  the  clamped  ligaments.  It  is 
thus  employed  :  '*  Through  the  posterior  opening  the  forefinger  is  car- 
ried over  the  top  of  the  broad  ligament,  hooking  it  down  as  far  as  pos- 
sible. The  posterior  blade  is  now  carried  upwards  along  the  finger  at 
a  distance  of  about  i  inch  from  the  uterus,  and  the  end  looped  over 
the  top  of  the  ligament.  Its  handle  is  pressed  backwards  on  the 
perineum.  The  anterior  blade  is  introduced  in  front  of  the  ligament, 
parallel  to  the  posterior  blade,  and  its  end  locked  by  a  simple  mechan- 
ism. The  clamp  is  then  closed  and  screwed  up  tightly  outside  the 
vulva.  A  second  clamp  is  similarly  applied  on  the  opposite  ligament, 
A  knife  is  run  up  the  grooves  and  the  ligament  divided  on  the  uterine 
side  of  the  clamj^s,  when  the  uterus  is  freed."  The  instruments  may 
be  easily  removed  at  the  end  of  two  or  three  days,  without  haemor- 
rhage. 

For  cases  unsviited  for  the  clamps — e.g.,  enlarged  uteri — the  same 
surgeon  recommends  the  plan  of  turning  the  uterus  upside  down,  and 
using  forcipressure  or  ligatures,  "Complete  rotation  of  the  uterus 
on  its  long  axis  materially  shortens  the  depth  of  the  broad  ligaments, 
brings  them  more  fully  within  the  field  of  operation,  and  leaves  the 
most  important  stage  of  the  proceeding — division  of  the  uterine  arte^ 


732  OPERATIONS  ON  THE  ABDOMEN. 

ries — to  the  last,  when  it  is  also  rendered  more  easy.  It  matters  little 
whether  the  uterus  is  turned  backwards  or  forwards.  If  rotation  can 
be  performed  by  the  finger  alone,  it  is  most  easily  carried  out  in  the 
backward  direction,  with  the  finger  in  the  posterior  opening,  hooked 
over  the  fundus.  If  the  finger  does  not  suffice,  anterior  rotation  by 
means  of  forceps  may  be  carried  out.  A  firm  hold  of  the  anterior 
surface  is  taken  hold  of,  and  the  uterus  pulled  down  as  much  as  pos- 
sible ;  a  second  hold  is  secured  higher  up,  and  so  on,  one  above  the 
other,  till  the  fundus  is  grasped,  and  the  uterus  pulled  down  and  com- 
pletely inverted.  The  fundus  now  lies  in  the  vagina,  and  perhaps 
presents  at  the  vulva,  and  the  upper  insertions  of  the  broad  ligaments 

are  within  sight  and  reach With  an  inverted  uterus,  deligation 

of  the  broad  ligaments  presents  no  especial  difficulties.  Firstly,  a 
powerful  Wells'  forceps  grasps  as  much  as  possible  of  one  broad 
ligament,  close  to  the  uterus,  and  a  strong  silk  ligature  is  carried  round 
a  corresponding  depth  of  the  ligament  at  a  proper  distance  beyond. 
The  intervening  tissue  is  divided  with  scissors.  Two  or  three  successive 
pieces  of  ligament  are  so  treated,  and  one  side  of  the  uterus  is  set  free. 
The  other  side  is  similarly  treated,  and  the  whole  uterus  is  then  re- 
moved. The  broad  ligaments  are  thus  secured  by  three  or  four  liga- 
tures on  each  side,  and  they  are  cut  short.  If  there  is  any  doubt  as 
to  the  securing  of  the  deligation  at  any  point,  a  catch  forceps  is  placed 
on  the  visible  vessels,  or  the  forceps  are  left  hanging,  and  removed 
next  day  or  the  day  after.  Ovaries  and  Fallopian  tubes,  if  healthy, 
need  not  be  removed.  When  the  uterus  is  pulled  down,  and  particu- 
larly if  it  is  inverted,  the  broad  ligaments  are  stretched  and  tense.  As 
soon  as  the  uterus  is  cut  off,  the  ligaments  recoil,  become  flaccid,  and 
retract,  tending  to  cast  ligatures  loose.  Therefore  these  should  be 
tightly  drawn  and  should  have  a  considerable  hold  upon  the  tissues. 
These  precautions  ought  to  be  especially  observed  in  the  lower  por- 
tions of  the  ligaments,  where  the  uterine  arteries  lie.  And  it  must  be 
remembered  that  it  is  here  where  the  risks  of  wounding  the  ureters,  or 
of  including  them  in  the  ligatures,  is  greatest.  These  dangers  are  en- 
hanced by  inversion  of  the  uterus.  They  are  minimized  by  a  thorough 
separation  of  surrounding  cellular  tissue  in  the  early  stages,  and  by 
keeping  always  as  close  to  the  uterus  as  possible." 

No  sutures  should  be  employed.  As  the  sponge  is  withdrawn  the 
flaps  tend  to  fall  together.  A  drainage-tube  is  inserted,  and  irrigation 
is  practiced  by  a  catheter  passed  along  this.  Plugging  of  the  vagina 
is  thought  unnecessary.  The  genitals  must  be  kept  scrupulously  clean. 
If  haemorrhage  occur,  an  ana:'sthetic  must  be  given  and  the  bleeding 
looked  for  and  secured  by  forceps  left  attached.  Ooidng  may  be 
checked  by  syringing  with  hot  water. 


C.E^ARIAN    SECTION.  733 

Contrast  of  the  Abdominal  and  Vaginal  Operations. — 

The  former  of  these  has  been  practically  abandoned  (_)\vinu-  to  its 
fatality,  the  mortality  being  about  70  per  cent.  Mr.  Greig  Smith  {he. 
supra  ciL,  p.  18D  gives  the  mortality  of  the  vaginal  method  as  under 
27  per  cent.  The  dangers  common  to  the  two  methods,  shock,  septi- 
caemia, peritonitis,  inclusion  of  the  ureter,  secondar}^  haemorrhage, 
seem  to  be  better  avoided  by  the  simple  vaginal  method.  Mr.  Greig 
Smith  thus  expresses  his  belief  that,  in  carefully  selected  cases,  the 
operation  is  both  justifiable  and  proper.  "  The  immediate  mortality 
does  not  forbid  it.  Recurrence  is  almost  certainly  not  more  rapid  than 
in  other  operations  for  cancer,  and  permanent  recovery  is  just  as  likely 
to  be  secured.  And,  finally,  there  seems  to  be  an  almost  unanimous 
opinion  that  death  after  recurrence  is  not  attended  with  so  much 
suffering,  that  perforations  of  bladder  and  rectum  are  not  so  liable  to 
take  place  after  the  uterus  is  removed,  and  that  existence  is  prolonged." 
Mr.  Thornton  (Did.  of  Surg.,  vol.  ii.  p.  753)  thus  concludes  his  ac- 
count of  the  operation :  "  Time  alone  can  decide  w'hether  complete 
extirpation  of  the  uterus  for  cancer  is  destined  to  establish  for  itself  a 
permanent  place  in  surgery,  or  is  to  sink  into  oblivion  again,  as  it  has 
already  done  in  the  past,  after  a  very  decided  attempt  to  establish  it, 
though  not  on  such  a  careful  and  scientific  basis  as  in  the  present 
revival  of  the  operation." 

O^SARIAN  SECTION.^ 

The  preparatory  treatment  is  much  the  same  as  in  ovariotomy.  The 
same  care  must  be  taken  to  provide  suitable  sponges,  pressure-forceps, 
and  a  sufficiency  of  sutures  and  ligatures. 

An  incision,  about  5  inches  long,  is  made  as  in  ovariotomy,  but  does 
not  descend  within  at  least  2  inches  of  the  pubes,  for  fear  of  injuring 
the  bladder.  Especial  care  must  be  taken  in  opening  the  peritoneum 
not  to  wound  the  uterus.  If  possible  the  placental  site  should  be 
made  out  (a  matter  often  of  great  difficulty)  before  opening  the  uterus, 
and  avoided.  The  surgeon,  having  decided  where  to  incise  the  uterus, 
takes  the  following  steps  to  prevent  fluids  escaping  into  the  peritoneal 
cavity  :  (1)  By  packing  sponges  (previously  counted)  carefully  around 
(2)  By  an  assistant  keeping  the  parietes  firmly  pressed  against  these 
and  the  uterus.  (3)  By  another  with  his  hand  behind  the  uterus  causing 
it  to  protrude  into  the  wound,  and  firmly  holding  it  there  (Greig  Smith). 

An  incision  4  to  5  inches  long  is  then  made  in  the  uterus,  first  by 
an  incision  partly  through  in  the  upper  part,  which  is  completed  with 

*  I  trust  that  in  including  the  following  short  acconnt  of  this  operation  I  shall  not 
be  met  with  the  criticism  "  ae  sutor  ultra  crepidam."  My  excnse  wonld  be  that  this  is 
an  operation  which,  in  the  country  especially,  any  hospital  surgeon  may  be  sent  for  to 
perform,  and  that  without  niucli  notice. 


7c54  OPERATIONS    ON    THE   ABDOMEN'. 

the  finger,  and  then  by  carrying  this  downwards  with  scissors.  The  hand 
being  rapidly  inserted  i^artly  closes  the  opening  and  finds  the  neck  of 
the  child,  which  is  extracted  head  first.*  All  this  time  the  entrance 
of  blood  and  amniotic  fluid  must  be  prevented  by  the  above-given 
precautions.  The  cord  being  divided  between  two  pairs  of  Spencer 
Wells'  forceps,  the  surgeon  attends  next  to  the  bleeding  and  the  pla- 
centa. If  the  uterus  is  contracting  well,  hasmorrhage  will  cease  and 
spontaneous  detachment  will  take  place.  If  there  is  no  time  to  wait 
for  this,  the  placenta  must  be  carefully  peeled  away  while  bleeding 
sinuses  are  compressed  with  sponges,  or,  if  needful,  with  Spencer 
Wells'  forceps.f 

The  most  important  step,  closure  of  the  uterine  wound,  remains. 
The  membranes  being  removed  and  the  uterus  contracted,  superficial 
and  deep  sutures  of  carbolized  silk  are  then  inserted  by  the  Siinger- 
Leopold  method,  which  relies  ujDon  the  peritoneum  for  the  most  per- 
fect closure  of  the  uterine  wound.  It  is  thus  described  by  Mr.  Greig 
Smith  :  "  The  peritoneal  covering  is  detached  from  the  muscular  fibre 
for  a  little  distance  along  the  margins  of  the  wound :  in  this  way  it  is 
possible  to  turn  inwards  a  greater  surface  of  peritoneum.  Then  the 
deep  sutures  are  placed.  They  are  made  to  enter  about  ^  inch  from 
the  edge  of  the  wound,  passed  obliquely  through  uterine  tissue,  and 
made  to  merge  near  the  bottom  of  the  cut  surface.  No  suture  should 
enter  the  uterine  cavity.  These  deep  sutures  should  be  placed  about 
4  inch  apart ;  and  they  should  be  carried,  converging  a  little,  beyond 
the  ends  of  the  incision.  Then  the  superficial  sutures  are  placed,  two 
between  each  deep  suture.  The  needle  first  pierces  peritoneum  and 
muscle,  coming  out  a  little  below  the  lip  of  the  wound  ;  then  it  picks 
up  the  free  edge  of  the  peritoneum  on  its  own  side,  and  finally  pursues 
the  same  course  in  the  opposite  direction  with  the  other  side."  These, 
also,  are  carried  a  little  way  beyond  the  margins  of  the  wound.  The 
superficial  are  first  tied,  then  the  deep.  Finally,  if  apposition  is  not 
perfect,  a  few  more  sutures,  or  a  continuous  one,  may  be  used.  While 
the  sutures  are  being  inserted  fresh  sponges  may  be  inserted.  The 
peritoneum  is  then  most  carefully  dried  and  cleansed.  Drainage 
should  be  used,  as  after  ovariotomy,  if  there  is  any  suspicion  of  fluids 
in  the  peritoneal  cavity.  And  if  much  oozing  has  taken  place  from 
the  uterine  walls,  or  if  the  discharges  are  foul,  a  tube  should  be  passed 
from  the  uterus  into  the  vagina  before  the  sutures  are  placed.  While 
the  abdominal  wound  is  being  closed,  an  assistant  syringes  out  the 
vagina  with  a  Higgenson's  syringe  and  plugs  it  with  iodoform  or  sal 
alembroth  gauze. 

*  If  the  feet  are  taken  first,  the  uterus  may  contract  around  tlie  head. 

f  A  hypodermic  injection  of  ergotin  may  be  given,  and  the  uterus  tirmly  grasped. 


REMOVAL  OF  GROWTHS  OF  THE  BLADDER.         735 

CHAPTER  XII. 

OPERATIONS  ON  THE  BLADDER. 

REMOVAL  OF  GROWTHS  OF  THE  BLADDER —LATE- 
RAL LITHOTOMY.  — SUPRA-PUBIO  LITHOTOMY.— 
MEDIAN  LITHOTOMY.-LITHOTRITY  AND  LITHOLA- 
PAXY.  —  REMOVAL  OF  STONE  IN  THE  FEMALE  — 
CYSTOTOMY.— RUPTURED  BLADDER. 

REMOVAL  OF  GROWTHS  OF  THE  BLADDER. 

Practical  Points  in  the  Diagnosis.— Indications  for  Oper- 
ation. 

Hfemorrhage. — This  is  of  much  importance,  both  in  diagnosis  and 
as  bearing  upon  an  operation.  Thus,  in  the  villous  growth  or  fimbri- 
ated papilloma  it  is  this  alone  which  kills.  In  these  growths  the  chief 
point  is  that  the  hsemorrhage  extends  over  a  long  time,*  occurs  spon- 
taneously and  suddenly,  and  ceases  in  the  same  way;  the  periods  of 
intermission  gradually  become  less,  till  the  bleeding  is  constant,  either 
rendering  the  patients  utterly  anaemic  or  adding  to  their  misery  by 
bringing  about  cystitis.  These  last  two  conditions  may  be  so  marked 
as  to  demand  an  operation.  This  symptom  is  most  frequent  in  the 
villous  growth  (fimbriated  papilloma),t  less  so  in  the  fibro-papilloma 

*  Mr.  R.  Harrison  {Intern  Encycl.  Surg ,  vol.  vi.  p.  38)  states  that  in  the  museum 
of  St.  George's  Hospital  there  is  a  specimen  of  a  villous  tumor  attached  to  the  neck  of 
the  bladder  of  a  gentleman  aged  eighty-one.  The  first  attack  of  haemorrhage  had 
occurred  twenty  years  before  death,  and  had  lasted  for  eight  months,  an  interval 
of  four  years  had  followed  this,  and  then  a  recurrence  of  haemorrhage,  which  ulti- 
mately proved  fatal.  Sir  B.  Brodie  also  states  that  the  disease  occasionally  extends 
over  seven  or  eight  years.  In  a  case  of  Mr.  Anderson's  {Clin.  Soc.  Trans.,  vol.  xviii. 
p.  313),  of  papilloma,  the  first  hsematuria  had  taken  place  twelve  years  before;  then 
came  an  interval  of  a  year,  followed  by  recurrence  of  the  hsematuria,  the  next  in- 
terval being  shortened  to  six  months,  after  which  recurrence  took  place  fairly  reg- 
ularly every  three  months. 

f  Sir  H.  Thompson  (hic.  infra  cil.)  clas-sifies  tumors  of  the  bladder  as  follows:  1. 
Simple  mucous  polypus  or  myxoma ;  2.  Papillomata — (a)  Fimbriated  papilloma  or 
villous  tumor,  (6)  Fibro-papiiloma ;  3.  Transitional  tumors,  intermediate  in  structure 
between  the  foregoing  and  the  sarcomata ;  4.  Sarcomata,  round  and  spindle-celled 
(rare);  5.  Scirrhous,  encephaloid,  and  melanotic  cancers;  6.  Dermoid  tumors  (rare). 
A  more  scientific  classification  is  that  given  by  Prof.  Kuster  in  Volkmann's  Clin.  Lect., 
Annals  of  Surgery,  September,  1886:  A.  New  growths  of  the  prostate — 1.  Fibro-ade- 
noma,  2.  Myxoma,  3.  Carcinoma.  B.  New  growths  of  the  bladder — i.  New  growths 
from  the  mucous  or  sub-mucous  coat:  1.  Papilloma  (including  the  two  varieties  of 
Sir  H.  Thompson),  2.  Fibrous  polypi  and  myxoma,  3.  Sarcoma ;  ii.  New  growths 
from  muscular  coat :  4.  Myoma  ;  iii.  New  growths  from  the  epithelial  and  glandular 
tissues :  5.  Adenoma,  6.  Carcinoma. 


736  OPERATIONS  OX  THE  ABDOMEX. 

or  in  the  "  transitional "  growths.  Mr.  H.  Thompson*  lays  much 
stress  on  the  fact  that,  in  these  cases,  the  stream  often  begins  without 
or  with  little  blood,  and  ends  of  a  briglit-red  color. 

Sounding. — This  is  usuall}-  said  to  be  negative,  but  it  should  be 
made  use  of  thoroughly  and  carefully.  In  the  case  of  a  single  fimbri- 
ated papilloma,  the  sound  may  give  no  information  unless  it  happens 
to  detach  the  growth.  In  more  solid  growths — e.g.,  a  fibrous  papilloma, 
a  transitional  or  sarcomatous  tumor — resistance  may  always  be  met 
with  at  one  spot  in  moving  the  sound.t  In  the  mucous  polypi  of 
children  any  movements  of  the  sound  may  be  prevented,  and  carcino- 
mata,  if  ulcerated,  may  give  a  very  distinct,  uneven,  rugged  feel,  while 
the  increase  of  pain  afterwards  is  here  very  marked.  But  sounding 
is  of  value  beyond  what  it  tells  at  the  time.  By  using  the  sound  with 
judicious  and  gentle  vigor,  particles  of  a  villous  growth  may  be  de- 
tached for  microscopical  examination.  This  may  perhajis  be  aided 
by  washing  out  with  a  lithotrity  evacuator  as  suggested  by  Mr.  Davies- 
Colley. 

Examination  of  Urine. — This  aid  has  been  too  much  neglected  be- 
cause the  naturally  present  "transitional  "  epithelium  of  the  bladder 
may  so  easily  be  mistaken  for  growth-cells.  But  in  the  case  of  villous 
growths  especially,  careful  examination  of  the  urine  should  be  fre- 
quently made,  and  the  patient  directed  to  bring,  at  once,  any  white  or 
flocculent  particles  passed.  The  sediment  of  the  urine  should  be  also 
frequently  examined  microscopically  after  sounding  and  washing  out. 
The  delicate  papilla^,  with  their  connective-tissue  basis  supporting 
hosts  of  columnar  cells  with  large  delicate  capillaries,  are  most  char- 
acteristic. 

Examination  per  Rectum. — This  is  usually  negative.  Occasionally 
pam,  a  tender  spot,  or  thickening  felt  through  the  trigone,  may  point 
to  the  position  of  the  growth.  In  elderly  men  a  rectal  examination 
should  always  be  made  to  find  out  if  any  enlargement  of  the  prostate 
exists. 

Exclusion  of  other  Conditions — e.g.,  stone,  tubercular  and  other  forms 
of  cystitis.  The  need  of  this  is  so  obvious,  and  it  can  usually  be  so 
easily  managed  by  carefulness,  that  merely  mentioning  it  here  will  be 
sufficient. 

Failure  of  Previous  Treatment.— Growths  of  the  bladder  being  inevi- 
tably fatal,  whether  from  haemorrhage,  or  pain,  or  obstruction  results, 
or  from  these  combined,  the  surgeon  is  entirely  justified  in  urging  a 


*   Tumors  of  the  Bladder,  \t.  66. 

f  Tims  it  may  be  easy  to  explore  one  side  of  the  bladder  by  carrying  the  sound 
over  to  the  opposite  thigh,  while  similar  manoeuvres  to  examine  the  other  side  are 
interfered  with. 


REMOVAL    OF    GROWTHS    OF    THE    BLADDER.  737 

digital  exploration  to  clear  up  the  case  and  the  question  of  removal. 
While  it  remains  as  yet  uncertain  how  many  of  the  cases  published 
as  cures  are  really  and  permanently  so,  even  in  the  case  of  the  villous 
growth,  it  is  an  undoubted  fact  that  an  operation  may  result  in  arrest- 
ing the  hjemorrhage  completely  for  years.  In  other  cases,  hsemorrhage, 
pain,  and  frequency  of  micturition  may  all  be  very  largely  relieved. 
Where  little  or  nothing  can  be  done  in  the  way  of  removal,  the  free 
escape  given  to  the  urine  by  a  perineal  or  supra-pubic  operation  or 
by  dilating  the  neck  of  the  bladder  in  a  woman  may  give  great  relief; 
where  even  this  fails,  the  case  has,  at  least,  been  cleared  up. 

Choice  of  Operaiion. — Where  the  surgeon  has  to  deal  with  a 
large  tumor,  or  with  a  number  of  tumors,  the  supra-pubic  method  will 
be  safest  and  give  most  room,  and,  in  any  case  if  the  perineum  be  very 
deep,  if  the  prostate  be  enlarged,  or,  if  the  perineum  be  small  and  the 
pelvis  contracted,  the  above  operation  is  indicated.  So,  too,  in  the 
case  of  a  recurrent  growth,  this  method  should  be  employed,  as  it 
cannot  be  told  how  far  the  recurrence  is  widely  diffused. 

But  where  there  is  reason  to  believe  that  the  growth  is  single,  or 
small,  or  near  the  neck,  the  bladder  may  be  explored  from  the  peri- 
neum by  opening  the  membranous  urethra,  and  dilating  the  vesical 
neck. 

In  most  cases  it  will  probabl}-  be  advisable  to  combine  both  opera- 
tions, as  the  perineal  opening  enables  the  surgeon  to  use  two 
index-fingers  in  the  bladder  at  the  same  time,  and  also  favors  drainage. 

Operation. — The  surgeon  first  opens  the  membranous  urethra  on 
a  staff  in  the  manner  of  a  median  lithotomy  (p.  756),  and  explores 
the  bladder  after  dilating  the  neck  with  his  finger,  which  is  made  to 
enter  by  a  careful  insinuating  movement  along  the  director,  which  is 
then  withdrawn.  If  no  growth  is  felt  near  the  neck,  the  surgeon, 
rising,  makes  firm  supra-pubic  pressure,  so  as  to  bring  the  upper  part 
of  the  bladder  into  contact  with  his  left  index.  On  finding  a  growth, 
he  carefully  ascertains  its  size,  situation,  shape,  existence  or  not  of  a 
peduncle,  and  whether  this  peduncle  is  narrow  or  not.  Its  structure 
is  also  examined,  whether  polypoid  and  firm,  or  soft,  floating,  and 
villous.*  If  he  decide  that  the  growth  can  be  removed  by  the  perineal 
wound,  he  must  be  provided  with  appropriate  forceps,  especially  the 
ones  with  serrated  edges,  straight,  and  of  different  curves,  introduced 
by  Sir  H.  Thompson.  A  very  small  ecraseur  with  violin-string  liga- 
ture may  perhaps  be  used  in  this  way,  or  sharp  spoons  or  scoops.  Sir 
H.  Thompsonf  thus  describes  the  use  of  the  forceps :  Having,  with 

*  A  ragged  ulcerated  surface,  large  sessile  tiiniors,  and  multiple  soft  masses,  are  tlie 
most  unfavorable  to  deal  witii.  Beyond  a  p;illiative  cystotomy  the  first  admits  of  no 
interference. 

f   Tumors  of  the  Bladder,  p.  50;  Brit.  Med.  Journ.,  1883,  vol.il.  p.  1180. 

47 


738  OPERATIONS    ON    THE    ABDOMEN. 

his  forefinger,  first  made  himself  familiar  with  the  exact  position  and 
size  of  the  tumor,  he  inserts  the  forceps,  guided  only  by  the  knowledge 
thus 'acquired,  and  makes  a  decided  snip  on  the  tumor;  then,  by 
moving  the  forceps  in  different  directions,  he  makes  sure  that  he  has 
the  growth  within  their  grasp.  "Above  all  things,  he  is  not  to  pull 
forcibly,  but  to  press  firmly  the  blades  together,  biting  or  chewing  a 
little,  if  I  may  use  the  terms,  with  the  extremities  of  the  blades  with- 
out changing  the  original  situation  of  the  bite  or  grasp.  Then  a  little 
twisting  movement  may  help  to  disengage  the  mass,  which,  if  accom- 
plished, the  forceps  will  be  felt  free,  and  maybe  withdrawn  with  their 
contents,  after  which  the  finger  enters  to  feel  what  remains  and  what 
more  must  be  done  in  order  to  complete  the  removal.  Let  me  remark, 
whenever  the  force23S  has  removed  a  portion,  however  small,  the  in- 
strument should  never  be  re-introduced  until  the  finger  has  again 
examined  the  interior."  It  is  best  to  leave  the  detached  pieces  in  the 
bladder  and  to  remove  them  together  at  the  end  with  a  scoop. 

If  the  tumor  has  not  been  separated  by  the  moderate  use  of  the 
forceps  just  described,  it  will  probald}'  be  found,  on  introducing  the 
finger,  so  nearl}^  severed  that  the  actual  division  may  be  completed 
with  the  finger  nail  or  by  one  of  Sir  H.  Thompson's  serrated  instru- 
ments for  this  purpose. 

The  same  surgeon  thus  draAvs  attention  to  the  great  risk  of  making 
strong  supra-pubic  pressure  while  forceps  are  being  used  :  "  If  that 
pressure  is  considerable,  it  forces  the  upper  wall  of  the  bladder  into 
its  own  cavity,  and  thus  gives  the  growtlis  a  larger  contour  than  they 
possess,  and  makes  them  apparently  salient  to  a  much  greater  extent 
than  they  really  are.  Thus,  an  eager  or  inexperienced  operator,  un- 
aware of  the  eff'ects  of  strong  supra-pubic  pressure,  might  be  led  to 
seize  the  mass  offered  to  the  forceps  through  the  influence  of  this  pres- 
sure, and,  under  the  belief  that  it  was  a  large  growth,  he  might  inflict 
a  fatal  wound  by  crushing  a  double  fold  of  the  coats  of  the  bladder, 
and  so  make  an  opening  in  the  peritoneum.  To  avoid  such  a  catas- 
trophe, it  is  only  necessary,  first,  to  decline  the  attempt  to  destroy  any 
growth  which  is  clearly  not  sufficiently  salient  to  admit  of  complete 
or  nearly  complete  removal ;  and,  secondly,  never  to  employ  the  for- 
ceps while  forcible  supra-pubic  pressure  is  made — at  least,  no  more 
pressure  than  is  desirable  just  to  steady  and  support  the  bladder  and 
the  parts  adjacent." 

When  a  growth  has  a  sufficiently  long  and  substantial  pedicle,  it 
may  be  dragged  out  into  the  wound  and  cut  away  or  twisted,  or 
divided  with  the  ecraseur  in  the  way  adopted  by  Mr.  Davies-Colley* 
and  Mr.  Pittsf  in  their  cases. 

*  ain.  Soe.  Trans,   vol.  xiv.  p.  104.  f  Ihid.,  vols  xviii.  p.  321  ;  xx.  p.  369 


REMOVAL  OF  GROWTHS  OF  THE  BLADDER.         739 

If  the  surgeon  determine  to  make  a  supra-pubic  opening  as  well, 
owing  to  the  growth  being  large,  multiple,  beyond  reach,  etc.,  he  will 
first  place  a  bag  in  the  rectum  and  distend  it  with  10  or  12  ozs.  of 
water.  The  bladder  is  then  injected  with  8  or  10  ozs.  of  Thompson's 
fluid  (p.  bl9j  through  the  perineal  wound  by  a  large  catheter,  and 
this  wound  is  finally  plugged  around  the  catheter  with  sponges  dusted 
with  iodoform,  aided,  if  needful,  by  the  finger  of  an  assistant.  The 
supra-pubic  opening  is  then  made  as  at  p.  753,  with  this  exception, 
that,  when  the  bladder  is  distinctly  reached,  one  or  two  sutures  of  car- 
bolized  silk  are  passed  across  the  site  of  the  intended  opening"  into  the 
bladder  with  a  curved  needle  in  a  handle.  The  opening  into  the 
bladder  is  then  made  (carefully,  so  as  not  to  divide  the  underlying 
silk),  the  silk  is  hooked  up  and  divided;  by  this  means  two  or  four 
sutures  are  present — one  or  two  on  either  side — which  will  serve  to 
raise  up  the  bladder  as  required,  and  to  keep  it  well  open  and  within 
reach  during  the  manipulations  needful  for  the  removal  of  the  tumor. 
This  may  be  effected  by  the  finger-nail,  one  working  from  the  upper 
and  another  from  the  perineal  opening,  or  by  one  of  the  instruments 
already  mentioned. 

The  galvanic  ecraseur  sliould  never  be  used  unless  other  instru- 
ments have  failed.  The  loop  will,  no  doubt,  shear  away,  without 
ha:!morrhage,  large  masses  which,  from  their  size,  poorly  marked 
pedicles,  and  vascularity,  are  very  difficult  to  deal  with  otherwise. 
But  its  liability  to  introduce  septic  complications,  and  the  difficulty 
of  manipulation  in  a  deep  contracted  space,  are  grave  objections  to  the 
cautery.*  If  the  surgeon  is  driven  to  use  an  ecraseur,  he  should 
employ  the  ordinary  wire  one,  on  account  of  the  above-mentioned 
septic  complications.  Wiih  regard  to  the  size  of  the  tumor,  it  is  re- 
markable, if  the  anaesthetic  is  taken  well,  how  much  may  be  removed 
by  a  process  of  quiet  nibbling  combined  with  careful  torsion.  Mr. 
Bryant  (Lancet,  1886,  vol.  ii.  p.  1076)  found  the  following  method 
useful  in  the  case  of  a  bladder  which  appeared  to  be  filled  with  vil- 
lous growth  :  A  great  deal  having  been  removed  by  forceps,  the 
bladder  was  scraped  throughout,  the  walls  being  wiped  rather  roughly 
with  a  new  sponge  tightly  tied  round  a  forceps.  Haemorrhage  recurred 
six  months  later,  persisting  for  a  week ;  it  then  stopped,  and  the  man 
was  doing  well  eighteen  months  after  the  operation.  Whatever 
method  is  used,  the  surface  left  should  be  as  smooth  as  possible,  to 
diminish  the  risk  of  phosphatic  deposit. 

DifiBculties  during  Removal  of  Bladder  Tumors. 

1.  A  very  contracted  bladder. 

*  In  one  case  brought  before  the  Clinical  Society  {Lancet,  December  3,  1887)  Mr. 
Parker  used  tiiis  method  successfully,  examining  the  base  of  the  growth  and  every  part 
of  the  bladder  with  a  small  incandescent  electric  lamp  introduced  for  the  purpose. 


740  OPERATIONS  ON  THE  ABDOMEN. 

2.  Growths  very  large,  or  multiple  and  diffuse,  or  without  pedun- 
cles. Other  difficulties  connected  with  the  growth  may  be  its  situa- 
tion far  back  in  the  fundus,  or  its  structure  with  long  delicate  filaments, 
which,  floating  in  fluid,  are  difficult  to  detect  and  catch. 

3.  Hemorrhage.  This  may  be  very  troublesome,  and  obscure  the 
field  of  operation.  It  usually  yields,  either  spontaneously,  after  the 
removal  of  the  growth,  or  to  sponge-pressure,  injections  of  ice-cold 
boracic  acid,  or  dilute  solution  of  iron  perchloride. 

4.  Infiltration  of  the  bladder  wall  by  growth. 

Causes  of  Death  after  Removal  of  Bladder  Tumors. 

1.  Shock.  Mr.  R.  Harrison  {Lancet,  1884,  vol.  ii.  p.  678)  records  a 
case  of  a  man,  aged  forty-two,  who  died  somewhat  suddenly,  ap- 
parently from  shock,  twelve  hours  after  removal  of  a  villous  tumor  by 
the  perineal  method.  The  haemorrhage,  which  had  begun  four  3'ear8 
before,  had  for  a  year  been  persistent  and  considerable.* 

2.  Surgical  kidney. 

3.  Injury  to  the  bladder  and  peritonitis.  Mr.  Bryant  (Lancet,  1886, 
vol.  ii.  p.  1077)  mentioned  a  case  in  which  a  fibrous  polypus  was 
drawn  from  the  fundus  into  the  j^erineal  Avound  and  snipped  off. 
The  man  died  of  peritonitis,  and  a  small  hole  was  found  in  the 
bladder  at  the  site  of  the  removed  polypus. 

4.  Recurrence. 

LATERAL  LITHOTOMY  (Figs.  120-2). 

The  lateral  operation  will  be  described  under  the  following  heads : 

A.  Preparatory  Treatment. 

B.  Passing  the  Staff.    Possible  Difficulties. 

C.  Finding  the  Stone.    Possible  Diflaculties. 

D.  Entering  the  Bladder.    Possible  Diflaculties. 

E.  Extracting  the  Stone.    Possible  Diflaculties. 

F.  After-Treatment  and  Possible  Complications. 

A.  Preparatory  Treatment.— For  a  week  or  so  before  tlie  opera- 
tion the  diet  should  be  bland,  so  as  to  tax  as  little  as  possible  jaded 
kidneys — e.g.,  milk,  barley-water,  light  puddings,  and  a  little  fish. 
If  alcohol  is  needed,  some  sound  spirit,  well  diluted,  will  be  a  good 
form.  Baths  should  be  taken  regularly,  the  bowels  well  moved,  and 
an  enema  given  on  the  morning  of  the  operation,  and  care  should  be 
taken  that  all  this  has  come  away. 

*  Mr.  Harrison,  in  illustration  of  the  sudden  and  excessive  bleedinj;:  to  wliich  villous 
tumors  are  liable,  even  when  they  appear  comparatively  quiescent,  has  published 
{Liverpnol  Med  Chir.  Joiirn ,  July,  1884),  a  case  where  death  took  place  from  this 
cause  in  nine  hours.  In  this  instance  slight  hsematuria  had  existed  for  some  months 
previously,  but  no  operation  liad  been  performed. 


LATERAL    LITHOTOMY.  741 

B.  Passing  the  Staff. — This  step,  however  simple  and  easy, 
usually  presents  occasional  difficulties,  the  more  trying,  because  per- 
haps unlocked  for  ;  they  are — 

(1.)  Spasm,  from  the  urethra  not  being  used  to  instruments. 
(2.)  Stricture. 
(3.)  False  passage. 
(4.)  Enlarged  prostate. 

(5.)  An  enlarged  prostatic  sinus,  into  which  the  end  of  the  sound 
passes. 

C.  Finding  the  Stone  with  Sound  or  Staff.  Possible 
Diflaculties. 

(1.)  The  stone  may  have  been  passed.*  This  is  not  impossible  in 
children  with  small,  smooth,  narrow  calculi,  and  their  sudden,  stren- 
uous micturition. 

(2.)  The  stone  ma}^  lie  behind  an  enlarged  prostate.  Here  the  finger 
of  an  assistant  passed  into  the  rectum  may  hel}). 

(3.)  The  stone  may  be  enveloped  in  folds  of  mucous  membrane. 
Injection  of  the  bladder  is  here  indicated, 

(4.)  The  stone  ma}''  be  encysted.  This  is  so  rare  as  to  have  been 
called  the  refuge  of  young  lithotomists.  The  following  case  of  Prof. 
Humphry!  shows  well  how  embarrassing  this  condition  may  be: 

A  man,  aged  fifty-one,  w^as  cut,  then  submitted  twice  to  lithotrity, 
then  again  cut  in  the  old  scar  three  times,  all  within  six  years,  for  an 
encysted  calculus.  On  the  fourth  occasion  of  lateral  lithotomy  the 
nature  of  the  case  was  made  out  accurately.  The  stone  was  uow  felt 
behind  the  prostate,  attached  to  the  bladder  by  a  pedicle  which  seemed 
to  penetrate  the  coats  of  the  viscus,  and  to  be  attached  to  another  mass 
beyond  it.  It  was  evidently  a  stone  of  hour-glass  shape,  part  being 
in  the  bladder  and  part  in  the  sac.  At  each  of  the  previous  operations 
the  part  within  the  bladder  had  broken  off,  the  rest  not  being  extracted, 
owing  to  the  size  of  the  prostate.  The  symptoms  recurring,  urethro- 
rectal lithotomy  was  performed.  The  stone  being  now  within  reach, 
the  edge  of  the  mucous  membrane  around  it  was  incised  with  a  her- 
nia knife,  and  a  stone,  the  size  of  a  walnut,  and  with  a  truncated  stalk, 
extracted.  Death  took  place  in  two  days,  from  pelvic  cellulitis. 
Though  the  bladder  was  otherwise  but  little  diseased,  the  cyst  seemed 
to  have  originated  from  the  protrusion  of  mucous  membrane  between 
the  muscular  fibres,  as  another  one  existed,  though  without  a  stone. 
The  cyst  communicated  by  a  considerable  opening  with  the  foul,  infil- 
trated tissues.  Prof  Humphry  asks  whether  this  was  due  to  his 
manipulations  of  a  delicate  sac,  and  whether  supra-pubic  lithotomy 


*  Cf.  the  case  mentioned  by  Mr.  FToltne-*,  Clin.  Soc.  Trans.,  vol.  ii.  p.  67. 
f  Some  Cases  of  OpercUion.     Pamphlet.     1856. 


742  OPERATIONS  OX  THE  ABDOMEN. 

would  not  have  been  better.  In  another  case  Prof.  Humpliry  was 
able  to  remove  a  similar  calculus  successfully,  by  lateral  lithotomy, 
after  repeated  introduction  of  force])S  and  scooj).  He  points  out  that 
these  cysts  may  be  quite  out  of  reach  in  lateral  litiiotomy.  As  their 
walls  consist  only  of  cellular  tissue,  mucous  membrane,  and  perhaps 
a  thin  layer  of  muscular  fibre,  they  are  easily  lacerated  during  an 
operation,  an  accident  almost  certain  to  be  fatal.  The  diagnosis  is 
usually  to  be  made  if  the  stone  is  always  struck  by  the  sound  at  one 
spot,  especially  if,  per  rectum,  a  lump  is  detected  corresponding  to 
that  spot.* 

D.  Entering  the  Bladder. — The  time  chosen  for  introducing 
the  staff' varies  with  different  operators.  Passing  the  staff'  while  the 
patient  is  still  recumbent  is  the  easier;  passing  it  when  the  patient  is 
in  lithotomy  position  is  rather  more  difficult,  but  secures  the  operator 
against  the  risk  of  the  staffs  slipping  out  after  the  patient  is  brought 
down  into  position,  a  risk  which  is  greater  with  the  straight  staff'.  I 
prefer  to  bring  the  patient's  lower  limbs  over  the  edge  of  the  table,  to 
pass  the  straight  staff"  while  he  is  thus  recuml)ent,  and  then  to  have 
his  limbs  only  brought  up  into  iDOsition. 

The  nates  just  projecting  over  the  edge  of  the  table,  the  sacrum  being 
flat  upon  it,  the  flexed  thighs  and  legs  being  held  well  out  of  the  way, 
the  surgeon,  seated  comfortably,  and  with  his  face  on  a  level  with  the 
perineum,  directs  an  assistant  so  to  hold  the  staff"  as  to  bring  the  mem- 
branous urethra  close  to  the  surface  of  the  perineum.  If  a  curved  staff 
be  used,  this  is  easily  done  by  inclining  the  handle  strongly  towards 
the  abdomen.  By  this  manoeuvre,  in  Mr.  Cadge's  words  {loc.  supra 
cit.)  the  point  of  the  staff' "need  not,  and  should  not,  be  withdrawn 
from  the  bladder,  but  if  it  were  it  would  be  of  no  moment,  because  it 
would  re  enter  it  the  moment  the  handle  is  raised  ;  the  membranous 
urethra,  instead  of  being  almost  perpendicular  to  the  surface  of 
the  perineum,  as  it  is  when  the  staff  is  held  upright,  is  brought  almost 
parallel  with  it,  and  is  much  easier  to  find  Avith  the  knife ;  there  is  no 
inducement  to  open  the  urethra  too  far  forwards,  and  consequently  no 
risk  of  wounding  the  bulb  or  its  artery.  The  staff"  gets  a  steady  rest 
against  the  front  of  the  puljes,  and  there  is  no  danger  to  the  rectum 
at  this  stage.'"! 

Having  felt  the  staff  thus  presented  towards  him,  having  examined 
into  the  depth  of  the  ischio-rectal  fossa,  the  site  of  the  tuber  and  ramus 

*  Erichsen  \Sur(/iry,  vol.  ii.  p.  945)  adds  that  the  heak  cannot  be  made  to  pass  round 
such  a  stone,  so  as  to  isolate  it. 

t  It  tluis  combines  the  advantages  of  the  two  very  diHerent  methods  usually  given, 
viz.,  either  to  hold  the  staff  well  up  firndy  under  the  pubes  and  tiius  away  from  the 
bowel,  but  also  away  from  the  stone;  or  closely  down  u[H}n  the  latter  and  in  proximity 
to  the  rectum  also. 


LATERAL    LITHOTOMY. 


743 


ischii,  the  surgeon,  pressing  up  the  junction  of  the  scrotum  and  raphe 
so  as  to  make  tense  the  parts  just  about  to  be  cut,  enters  his  knife  from 
4  inch  to  I2  inch  from  the  anus,  just  to  the  left  of  the  raphe,  and  very 


Fig. 120. 


(Fergusson.) 


likely  hits  the  groove  at  once.  The  knife  is  then  drawn  outwards  and 
backwards  with  a  rapid  sawing  movement,  to  a  point  midway  between 
the  anus  and  tuber  ischii,  thus  making  an  incision  of  2  to  3  inches, 
according  to  the  age  of  the  patient  and  size  of  the  stone.     Again  in- 


FiG.  12L 


(Fergusson.) 


serting  the  knife  into  the  upper  angle  of  the  wound,  the  surgeon  makes 
out  exactly  with  his  left  index  finger  the  groove  in  the  staff,  and  ex- 
poses this,  beyond  doubt,  in  the  wound.     The  next  steps  differ  some- 


744 


OPERATIONS  ON  THE  ABDOMEN. 


what,  accordingly  as  the  curved  or  straight  staff  is  used — they  will  be 
given  separately. 

(a)  With  the  Curved  Staff — When  the  knife-point  is  felt  firmly 
lodged  in  the  groove,  its  handle  is  a  little  depressed,  the  blade,  at  the 
same  time,  turned  a  little  to  the  left,  is  pushed  steadily  along  the 
groove  till  a  gush  of  urine  or  a  sense  of  resistance  ceasing,  or  both 
together  usually,  announce  tliat  the  neck  of  the  bladder  has  been  suf- 
ficiently divided  with  the  knife.  The  finger  is  now  wormed  into  the 
bladder  over  the  concavity  of  the  staff. 

(6)  With  the  Straight  Staff. — When  the  point  of  the  knife  is 
felt  to  be  safely  lodged  in  the  groove,  the  surgeon  takes  the  handle  of 
the  straight  staff"  from  his  assistant,  brings  it  down,  and  still  keeping 
his  knife  in  the  groove,  lateralizes  the  staff  slightly  to  the  left,  the 
handle  of  the  knife  being  now  depressed  so  as  to  form  a  sufficient 

Fig.  122. 


Lateral  lithotomy  with  a  straight  staff  (Key). 

angle  with  it,  and  make  an  adequate  wound,  the  surgeon  runs  it  along 
the  groove  steadily,  till  he  knows  by  the  above-given  evidence  that 
the  neck  of  the  bladder  has  been  sufficiently  cut. 

The  left  index  finger  is  next  wormed  over  the  edge  of  the  staff,  the 
straight  staff"  being  held  by  the  surgeon  himself,  in  his  right  hand, 
the  curved  one  being  held  by  an  assistant,  till  he  feels  that  he  has 
entered  the  bladder  and  placed  the  finger  tip,  if  possible,  in  contact 
with  the  stone.  Entrance  into  the  bladder  is  known  by  feeling  the 
finger  surrounded  with  a  smooth  cavity,  lined  with  mucous  mem- 
brane, while  the  finger  itself  is  girt  by  a  fibrous  ring.  The  stone 
being  felt,  or  the  bladder  cavity  distinctly  gained,  the  staff  is  with- 
drawn, and  the  surgeon,  while  taking  his  lithotomy  forceps,  dilates 
the  opening  into  the  bladder  with  his  finger,  which,  at  the  same  time, 
pulls  down  and  steadies  the  neck. 

Failure  to  Enter  the  Bladder. — This  most  vexatious  and  embarrassing 


LATERAL    LITHOTOMY.  745 

difficulty  is  most  likely  to  be  met  with  under  two  widely  different 
conditions — (1)  most  frequently,  in  little  children  ;  (2)  in  old  patients 
with  very  fat  deep  perinea,  and  enlarged  prostates.  Each  must  be 
considered  separately. 

(1)  In  Little  Children. — The  causes  here  are,  the  small  size,  delicacy, 
and  mobility  of  tiie  neck  of  the  bladder  and  urethra,  and  the  fact 
that  the  bladder  lies  high  up  above  the  pelvis.  Mr.  Cadge  quotes  the 
following  from  Sir  W.  Fergusson :  "  The  point  Avas,  as  usual,  placed 
on  the  staff  and  pushed  gently  towards  the  bladder.  The  finger  went 
on,  but  I  was  aware  that  it  had  not  got  between  the  urethra  and  the 
staff.  With  an  insinuating  movement  (much  to  be  appreciated  by 
the  lithotomist  who,  as  I  do,  professedly  inakes  a  small  incision  in 
this  locality),  I  endeavored  to  get  its  point,  as  usual,  into  the  urethra 
and  neck  of  the  bladder.  But  here  I  felt  convinced  that  I  had  failed, 
and  was  aware  that  the  finger  was  getting  deeper  as  regards  the  depth 
of  the  perineum,  but  that  I  was  not  materially  nearer  the  bladder. 
I  could  feel  a  considerable  space  at  the  point  of  the  finger,  and  was 
convinced  that  the  upi)er  part  of  the  membranous  urethra,  as  well  as 
the  sides,  had  given  way  to  the  pressure,  and  that  now,  as  the  finger 
was  getting  deeper  into  the  wound,  I  was  only  jDUshing  the  prostate 
and  neck  of  the  bladder  inwards  and  upwards.  These  parts  seemed 
to  recede  before  the  smallest  imaginable  force,  whilst  I  felt  that  I 
could,  in  a  manner,  make  any  amount  of  space  around  the  bare  part 
of  the  staff.  I  had  no  difficulty  in  distinguishing  between  the  surface 
of  this  space  and  that  of  the  mucous  membrane  of  the  bladder.  More- 
over, I  knew  that  I  had  never  crossed  that  narrow  neck  which  is  always 
felt  as  the  finger  passes  into  the  bladder  when  a  limited  incision  is 
made.  An  impression  came  over  me  that  I  was  about  to  fail  in  getting 
into  the  bladder,  and  I  had  an  idea  that,  unless  I  could  open  the 
urethra  in  front  of  the  prostate  more  freel}^,  I  should  probably  never 
reach  the  stone.  This  I  effected  with  great  caution,  and  then  I  could 
appreciate  the  passage  of  the  finger  as  usual  through  the  neck  of  the 
bladder.  The  stone  was  easily  touched  and  removed,  but  I  was 
forcibly  impressed  with  the  idea  that  I  had  nearl}^  f;iiled  in  the  per- 
formance of  the  operation."     The  child  here  was  four  years  old. 

Mr.  Cadge  thus  met  the  same  difficulty  in  an  infant  of  one  year  and 
a  half:  ''  I  felt  the  impossibility,  even  with  a  fair  incision,  of  distend- 
ing the  wound  with  my  finger ;  it  was  like  trying  to  get  it  into  the 
orifice  of  the  urethra.  I  therefore  desisted  before  doing  any  harm, 
and.  taking  a  pair  of  common  dressing-forceps,  I  passed  them  easily 
along  the  staff  into  the  bladder ;  by  opening  the  blades  gently  but 
firmly,  room  was  gained,  and  the  finger  entered  and  made  room  for 
small  lithotomy-forceps.     But  I  have  repeatedly,  after  passing  the 


746  OPERATIONS    ON    THE    ABD!>ME]Sr. 

dressing-forceps,  withdrawn  the  staff  and  removed   the  stone   with 
them,  and  without  introducing  the  finger  at  all." 

DiflBculties  and  Mistakes  during  this  Stage  of  entering  the 
Bladder. — This  is  so  important  a  part  of  the  operation  that  the 
following  may  be  enumerated  here  : 

1.  Finding  the  staff.  This  is  not  likely  to  present  difficulties  in  the 
case  of  a  curved  staff  if  it  be  held  as  advised  at  p.  742.  Hitting  a 
straight  staff  in  a  fat  child  is  not  always  easy,  owing  to  the  small  size 
which  is  needful.  Attention  must  be  paid  to  entering  it  at  the  root 
of  the  scrotum  only  just  to  the  left  of  the  raphe,  when  the  finger-nail 
will  detect  the  staff  at  once. 

2.  Not  exposing  the  staff.  Everything  which  lies  over  the  staff  in 
the  upper  angle  of  the  wound  must  be  clean  cut.  The  tissues  here, 
including  the  membranous  urethra,  are  lax  and  delicate,  and,  unless 
the  knife  is  clearly  in  contact  with  metal,  the  groove  will  not  be  fol- 
lowed. 

3.  Losing  the  groove.  This  most  serious  accident  may  be  due  to 
not  getting  the  knife  cleanly  into  the  groove,  not  keeping  it  sufficiently 
firmly  in  contact  with  it,  and,  thirdly,  by  forgetting  to  depress  slightly 
the  handle  of  the  knife. 

4.  Cutting  the  prostate  too  freely  as  the  knife  is  brought  out.  This 
can  easily  be  avoided  by  keeping  the  knife  sufficiently  near  to  the 
staff. 

5.  Cutting  into  the  rectum.  This  may  be  due  to  neglect  of  the 
following  precautions  :  (1)  Keeping  the  staff  up  away  from  the  bowel ; 
(2)  guarding  the  bowel  with  the  left  forefinger  in  the  wound;  (3) 
when  the  knife  is  lateralized,  cutting  away  from  the  gut. 

Mr.  Cadge  (loc.  supra  cit.)  points  out  that  the  usual  place  of  punc- 
ture is  the  dilated  part  just  above  the  internal  sphincter,  and  that  this 
communication  may  be  made  secondarily  by  sloughing  after  extrac- 
tion of  a  large  stone,  or  after  the  use  of  a  plug  for  arresting  haemorrhage. 
His  experience  is  that  "  Nature  seldom  fails  to  bring  about  a  cure,  or 
so  to  contract  the  wound  as  to  leave  but  trifling  inconvenience." 

6.  Wounding  the  posterior  wall  of  bladder.  Sir  S.  Wells,  at  the 
discussion  on  Sir  H.  Thompson's  paper  {Med.-Chir.  Soc,  April  2, 1878), 
mentioned  a  case  in  which  Mr.  Tyrrell  wounded  the  back  of  the  bladder, 
and  hence  always  advocated  a  short  knife. 

E.  Finding  and  Extracting  the  Stone.— The  surgeon's  left 
index  finger,  having  passed  into  the  bladder  along  the  convexity  of 
the  staff,*  finds  the  stone,  hooks  this  down  as  near  to  the  neck  as 
possible,  and  at  the  same  time  it  steadies  the  neck  while  it  dilates  the 
incision  in  it  and  in  the  prostate.     This  combination  of  movements 

*  This  is  only  withdrawn  wiien  the  stone  is  felt,  not  before. 


LATERAL    LITHOTOMY.  747 

requires  most  careful  attention  to  each  of  its  details  separatel^^  The 
most  important  of  these  is  the  dilatation  of  the  neck  and  prostate. 
If  the  stone  is  found  to  be  a  large  one  the  deep  part  of  the  wound 
must  be  sufficiently  free.  It  is  well  knoAvn  how  much  has  been 
written  on  this  matter.  The  surgeon  should  begin  by  dilating  the 
neck  of  the  bladder  carefully  and  equally  in  every  direction,  using  a 
considerable  amount  of  force  in  an  adult,  but  not  throwing  this  on 
any  limited  portion  of  the  wound.  It  may  be  accepted  as  a  certain 
fact  that  the  wound  in  the  prostate  may  extend  through  the  whole  of 
this  body,  without  risk  of  cellulitis,  if  only  the  recto-vesical  capsule 
is  not  torn  through.  As  long  as  the  finger  is  girt  by  a  fibrous  ring 
this  mischief  has  not  been  done.  Whether  an  extensive  wound  in  the 
prostate  had  better  be  made  by  dilatation  and  laceration  or  by  free 
incision  will  jDrobably  never  be  settled.  The  wise  surgeon  will  avail 
himself  of  a  safe  use  of  both — that  is  to  say,  after  dilating  with  forcible 
but  equal  pressure  all  around  the  original  wound  in  the  neck,  he  will 
introduce  a  blunt-pointed  narrow-bladed  bistoury  flat  against  the 
pulp  of  his  finger,  and  nick  the  remaining  constriction  at  one  or  two 
places,  cutting  rather  than  nicking  towards  the  right  side. 

Next  to  the  size  of  the  stone  the  age  of  the  patient  must  here  be 
considered.  After  middle  life  the  cellular  tissue  around  the  neck  of 
the  bladder  is  not  only  loose,  but  abounds  in  enlarged  veins.  Hence 
the  risk  of  causing  not  only  cellulitis  but  septic  i3hlebitis  by  dilating 
an  inadequate  opening  by  the  tearing,  bruising  exit  of  the  stone, 
instead  of  by  the  finger  and  knife  combined. 

The  deep  opening  being  thus  made  sufficiently  free,  the  surgeon 
having  selected  his  forceps,  introduces  them  along  the  finger  (thus 
further  dilating  the  woundy,  the  latter  being  withdrawn  as  the  forceps 
enter.  Tliese  held  at  first  in  one  hand  (the  thumb  in  the  ring)  are 
fully  introduced  closed,  then  opened  widely  transversely,  and  by  a 
quarter  turn  of  the  handles,  the  lower  blade  is  made  to  scoop  or  sweep 
along  the  floor  of  the  bladder,  which  will  almost  surely  catch  the 
stone.  If  this  step  fiiil  it  is  repeated,  and  if  the  stone  is  still  not 
caught,  the  surgeon  feels  again  for  the  stone  either  with  the  closed 
forceps  or  by  again  inserting  his  finger,  which  will  bring  down  the 
stone,  push  off"  projecting  folds  of  mucous  membrane,  etc.  Differently 
curved  foceps,  supra-pubic  pressure,  and  a  finger  in  the  rectum,  may 
all  help  now. 

The  stone  being  caught,  the  finger  again  feels  if  it  is  held  in  its 
shorter  axis ;  if  so,  it  may  at  once  be  extracted,  if  moderate  in  size, 
by  steady  deliberate  traction  downwards  and  outwards.  As  long  as 
the  stone  advances  all  is  well,  if  not  gentle  rotation  may  again  start  it 
on  its  way.  In  less  easy  cases  Mr.  Cadge's  words  should  be  remem- 
bered.    "  Should  there  be  much  resistance  and  no  sense  of  gradual 


748  OPERATIONS    ON    THE    ABDOMEN. 

yielding,  the  surgeon  will  ask  himself  whether  this  is  due  to  an  insuffi- 
cient opening,  or  to  the  projection  of  the  ends  of  an  oval  stone  laterally 
beyond  the  bladder.  This  latter  may  be  known  by  observing  that  the 
bladder  is  brought  bodily  down,  so  that  the  prostate,  which  is  probably 
large,  is  visible  near  the  external  wound  ;  in  this  case  the  stone  must 
be  liberated,  the  finger  again  introduced,  and  a  fresh  hold  taken.  If 
the  obstruction  is  due  to  a  large  stone  and  too  small  a  wound,  the 
latter  is  to  be  enlarged  in  the  direction  of  the  first  incision ;  this,  in 
the  opinion  of  the  writer,  is  preferable  to  making  the  division  of  the 
neck  of  the  bladder  on  the  opposite  side,  and  preferable,  too,  to  using 
undue  traction  and  force." 

In  some  cases  a  scoop  will  facilitate  extraction,  the  stone  being 
firmly  held  between  the  pulp  of  the  left  index  finger  and  the  concavity 
of  the  scoop.  In  children  one  finger  in  the  rectum  and  one  in  the 
bladder  will  often  serve  the  purpose. 

The  stone  being  out,  the  bladder  is  carefully  explored  with  the 
finger,  or  a  short-beaked  staff,  aided  by  pressure  above  the  pubes,  or 
from  within  the  bowel,  for  any  other  calculi  or  fragments.  Multiple 
calculi  will  have  been  indicated  by  facets  upon  the  first. 

Any  bleeding  vessels  are  now  secured,  and  the  patient,  wrapped  up 
in  blankets,  is  removed  to  bed. 

DiflQculties  during  the  Stage  of  Extraction  of  the  Stone. 

(1)  The  position  of  the  stone.  This  may  be  out  of  reach  owing  to 
its  being  at  the  posterior  part  of  a  dilated  bladder,  above  the  pubes, 
or  to  the  patient  having  a  very  fat  and  deep  perineum.  Pressure 
above  the  pubes  and  the  use  of  long  forceps  are  here  indicated. 

(2)  An  enlarged  prostate.  This  interferes  with  reaching  the  stone 
both  with  finger  and  forceps.  Curved  forceps  passed  in  along  the 
staff,  or  a  gorget,  if  the  perineum  be  very  deep,  will  be  helpful  here, 
and  perhaps  a  bag  in  the  rectum  would  aid  in  raising  up  the  stone 
within  reach  in  difficult  cases.  An  enlarged  middle  lobe  of  the  pros- 
tate, or  a  separate  adenonia  of  this  gland,  may  also  cause  trouble  by 
getting  between  the  blades  of  the  forceps.  Tearing  away  of  these 
portions  of  the  gland  has  often  occurred  and  is  sometimes  certainly 
beneficial.* 

(3)  Breaking  up  of  the  stone.  This  may  occur  with  hard  calculi 
from  too  much  force  being  used  with  the  forceps,  but  it  much  more 
often  happens  with  soft  phosphatic  calculi.      In   such   cases  every 

*  It  is  doubtful  if  tliis  is  always  so.  Thus  Mr.  Cadge  {loe.  supra  dt.)  tliinivs  "that 
it  is  probable  that  a  careful  examination  of  the  subsequent  condition  of  such  patients 
would  show  that,  although  it  may  not  have  endangered  life,  it  has  not  infrequently 
been  followed  by  partial  inability  to  retain  urine.  Prof.  Gross  (Trans.  Philad.  Path- 
Soc,  vol.  iv.  p.  158)  thought  that  in  one  case  the  cavity  left  behind  became  a  suppu- 
rating pouch,  and  increased  the  difficulty  in  micturition. 


SUPRA-PUBIC    LITHOTOMY.  749 

fragment  must  be  cleared  out,  a  matter  of  some  difficulty,  as  small 
ones  are  readily  concealed  in  clots  or  folds  of  mucous  membrane. 
After  all  the  larger  ones  are  picked  out,  a  catheter  of  appropriate  size, 
attached  to  a  Higgenson's  syringe,  is  inserted,  and  the  bladder  thor- 
oughly and  forcibly  washed  out  with  diluted  Thompson's  fluid  (1  in 
6  or  8)  (p.  619).  In  a  week  or  ten  days  the  bladder  should  again  be 
carefully  sounded,  and  examined  with  the  finger,  and  any  fragment 
extracted,  this  being  especially  needful  if  pain  has  persisted  after  the 
operation.*  If  fragments  still  persist  a  little  later,  an  evacuating- 
tube  and  washing-bottle,  aided  if  necessary  by  a  flat-bladed  lithotrite, 
must  l)e  employed.  I  may  here  express  my  belief  that  multiple  cal- 
culi are  not  quite  as  rare  as  has  been  supposed. 

(4)  Size  and  shape  of  the  stone.  Mr.  Erichsen  writes  on  this 
subject:  "A  calculus  about  H  inch  in  its  shorter  diameter  will  be 
hard  to  extract  through  an  incision  of  the  ordinar}^  length  (not  ex- 
ceeding eight  lines)  in  the  prostate,  even  though  this  be  considerably 
dilated  by  the  pressure  of  the  fingers  ;  and  I  think  it  may  be  safely 
said  that  a  calculus  2  inches  and  upwards  in  diameter  can  scarcely 
be  removed  by  the  ordinary  lateral  operation  with  any  degree  of  force 
which  it  is  safe  to  employ."  Most  will  agree  with  Mr.  Cadge  that 
stones  weighing  upwards  of  3  ozs.  will  be  dealt  with  by  the  improved 
supra-pubic  method. 

SUPRA-PUBIO  LITHOTOMY  (Figs.  123-5). 
Indications. — I  may  quote  here  from  a  paper  which  I  read  before 
the  Royal  Medico-Chirurgical  Society ,t  and  which  concluded  with 
the  following  propositions  : 

1.  "  That  supra-pubic  lithotomy,  as  recently  modified,  has  a  future 
of  renewed  usefulness  before  it,  and  that  while,  as  an  operation,  it 
can  never  contrast  with  the  rapid  brilliancy  of  the  lateral  operation, 
it  will  be  found  of  great  value  by  those  Avho  only  have  to  deal  with 
stone  occasionally,  and  by  those  who  find  themselves  face  to  face 
Avith  calculi  of  considerable  size  in  adults. 

2.  "  That  to  give  other  and  more  individual  instances,  the  operation 
will  be  found  useful  in  (a)  many  cases  of  hard  stones  of  1^  inch  in 
diameter;  (6)  in  multiple  hard  stones;  (c)  in  cases  of  calculus  not 
phosphatic,  occurring  with  enlarged  prostate ;  (d)  in  some  cases  of 
foreign  body  in  the  bladder  with  abundant  calculous  deposit  (Sir  H. 
Thompson). 

*  "Recurrence  of  stone  within  two  years  almost  always  means  that  a  fragment  has 
been  left  after  the  operation.  No  greater  disappointment  than  this,  both  to  the  sur- 
geon and  patient,  can  happen.  No  one,  probably,  has  cut  fifty  patients  without 
having  to  admit  and  lament  its  occurrence,  but  it  is  especially  liable  to  occur  to  the 
inexperienced  "  (Cadge). 

t  Trans.,  vol.  Ixix.  p.  377. 


750  OPERATIONS  ON  THE  ABDOMEN. 

"  In  the  rarer  cases  of  («)  a  state  of  urethra  which  will  not  admit 
the  use  of  a  lithotrite ;  (/)  in  a  very  deep  perineum  ;  ((/)  in  a  child 
with  deformed  pelvic  outlet ;  (h)  in  a  patient  with  ankylosed  hip- 
joint  not  admitting  of  his  heing  placed  in  the  usual  lateral  lithotomy 
position  (Sir  H.  Thompson). 

3.  "  That  at  present,  till  a  larger  number  of  cases  of  the  improved 
operation  have  been  collected,  it  will  be  wiser  not  to  attempt  to  close 
the  bladder  with  sutures. 

4.  "  That  in  reviving  an  abandoned  operation  these  two  questions 
call  for  an  answer  : 

"(a)  Do  we  stand  in  a  better  position  towards  the  operation  than 
our  predecessors  did  ? 

"  This  question  can  only  be  answered  in  the  affirmative  after  the 
work  done  by  Prof  Petersen  and  Sir  H.  Thompson. 

"(ft)  On  what  grounds  was  the  operation  abandoned?  The  chief 
of  these  appear  to  have  been,  (1)  the  absence  of  any  means  of  cer- 
tainly avoiding  the  peritoneum;  (2)  the  difficulty  of  sufficiently  and 
painlessly  distending  the  bladder  in  pre-ana?sthetic  days;  (3)  the 
absence  of  antiseptic  fluids;  (4)  the  fact  that  the  operation  was 
usually  reserved  for  very  large  stones,  and  that  it  was  often  performed 
for  such  stones  after  lateral  lithotomy  had  been  attempted  eitlier  on 
the  same  or  the  preceding  day." 

To  tbe  above  remarks  I  would  now  add,  speaking  from  a  larger 
experience,  tiiat  the  wound  here  is  slower  in  closing,  in  fact,  it  may 
not  heal  firmly,  as  long  as  the  urine  may  be  alkaline.  Occasionally 
it  reopens,  probably,  as  suggested  by  Petersen,  from  the  linea  alba 
uniting  before  the  bladder. 

The  greater  trouble  and  the  longer  time  which  this  operation  en- 
tails, both  during  its  performance  and  afterwards,  will  not  be  grudged 
in  these  days,  when  it  is  so  much  the  rule  to  pa}'-  attention  to  the 
details  of  surger3^  Only  time  and  a  larger  collection  of  cases  will 
show  how  far,  with  much  simpler  structures  to  cut,  w^ith  these  brought 
safely  into  reach,  and  with  modern  antiseptic  details  at  hand  in  the 
after-treatment,  this  lithotomy  is  safer  than  the  far  more  brilliant 
lateral  one. 

Details  of  the  Operation.  ■= 

A.  Distension  of  the  Rectum.  —  The  l)ag  used  for  this  must 
be  (1)  of  sufficient  strength!;  and  (2)  of  appropriate  size.     Thus,  it 

*  These  are  largely  taken  from  a  paper  of  mine  {Brit.  Med.  Journ.,  October  23 
and  30,  1886). 

t  M.  Guyon  {Ann.  cJe  Mul.  dcs  Organ.  Genito  urm,  t.  i.  p.  97)  mentions  a  case  in 
which  the  bag,  being  of  thin  india-rubber,  did  not  support  the  bladder  with  sufBcient 
firmness;  the  bladder,  thus  yielding  to  pressure,  was  diflBcuIt  to  open.  Any  addi- 
tional handling  of,  or  difficulty  in  opening,  the  bladder  must  increase  the  risks  of 
cellulitis. 


SUPRA-PUBIC   LITHOTOMY. 


751 


Fig.  123. 


should  be  of  as  soft  n.ibber  as  is  consistent  with  strength,  with  seams  as 
little  prominent  as  possible  *  and  flattened  rather  than  pyriform  in 
shape.  (3)  Theamountof  fluid.  A  flatf 
oval  bag  (Figs.  123,  124)  well  coated 
with  eucalyptus  and  vaseline,  entirely 
emptied. of  air  and  folded  up,  is  intro- 
duced well  above  the  sphincters  (the 
bowels  having,  of  course,  been  well 
emptied).  It  is  then  carefully  dis- 
tended by  means  of  an  easily  working 
syringe  with  water  varying  in  amount 
from  21  to  3  ozs.  in  a  child  of  five,  to 
10  or  12  ozs.  in  an  adult.  Sir  H. 
Thompson  gives  the  amount  in  the 
adult  as  12  to  14  ozs.  I  would  advise 
operators  to  be  content  with  the 
smaller  amount  at  first,  adding  a  little 
more  later  on,  if  needful,  and  only  to 
use  the  larger  amounts  in  special  cases 
— e.g.,  large  stones,|  doubtful  cases, 
or  where  a  growth  is  present  and  it 
is  desired  to  give  extra  elevation  and 
steadying  to  the  bladder. 

It  is  evident  that  with  such  large 
amounts  as  those  recommended  by 
some — e.g..,  M.  Guyon — serious  risk  is 
run  of  damaging  the  rectal  mucous 
membrane.  That  this  is  no  idle  fear 
is  proved  by  a  case  which  came  to  the 
knowledge  of  Mr.  Cadge,  in  which  15 
ozs.  ill  the  rectal  bag  caused  a  distinct 
tear  of  mucous  mem1)rane. 

B.  Distension  of  the  Bladder. 
— The  urine  being  first  drawn  off, 
8  to  10  ozs.  of  Thompson's  fluid  (borax,  1  pt.,  glycerine,  2  pts.,  water, 
2  pts. ),  diluted  1  in  6,  carbolic  acid  1  in  80,  mercury  perchloride  solu- 
tion 1  in  ]000,  are  generally  thrown  in  by  means  of  a  syringe  which 

*  In  two  of  my  earlier  cases  a  little  blood-stained  mucus  followed  the  withdrawal 
of  the  empty  bag;  no  ill  results  ensued,  and  as  this  did  not  occur  in  four  Inter  cases,  I 
think  it  may  be  attributed  to  the  use  of  the  earlier  bags  of  pyriform  shape,  stout 
rubber,  and  prominent  seams. 

t  The  pyriform  bags  tended  to  raise  only  the  centre  of  the  base  df  tlie  bladiler, 
leaving  two  lateral  sulci,  in  which  it  might  be  troublesome  to  find  the  stone. 

;|:  As  in  Sir  Henry's  cases. 


Oval  rectal  bag.  empty. 


752 


OPERATIONS   OX   THE   ABDO.MEX. 


works  smoothly,  and  whose  capacity  is  known.  In  children  from 
two  to  five  about  8  ozs.  will  he  sufficient.  The  jjatient  should  be  well 
under  the  influence  of  the  an£esthetic  at  this  time,  and  if  any  strain- 
ing takes  place  the  injecting  must  be  stopped,  the  hypogastric  region 
su})ported  with  two  hands,  and  some  fluid  allowed  to  run  out  if 
needful. 

It  may  not  be  out  of  place  to  remark  here  that  the  surgeon  Avill  do 
well,  when  injecting  rectum  and  bladder,  to  make  sure  that  he  is  in- 

FiG.  124. 


Oval  rectal  bags,  partly  distended.    A  child's  size  is  shown  below. 

jecting  fluids  only.  If  he  makes  trial  of  the  bag  outside  the  body, 
he  will  see  how  easy  it  is  to  send  in  air  as  well  as  fluids,  and  thus  to 
produce  more  distension  than  is  intended,  unless  the  bag  is  absolutely 
emptied  first,  and  unless  the  syringe  acts  perfectly.  By  the  double 
distension  of  rectum  and  bladder,  the  latter  will,  if  not  visible  to  the 
eye,  be  felt  by  the  left  hand  of  the  surgeon  (which  should  most  care- 
fully keep  touch  of  the  supra-pubic  region),  reaching  about  two- 
thirds  of  the  way  to  the  umbilicus. 

In  injecting  the  bladder,  often  irritable  in  these  cases,  the  surgeon 
must  keep  careful  count  of  its  resistance.  M.  Guyon's*  words  should 
now  be  remembered.  "On  pent  completement  supprimer  la  sensi- 
bilite  au  contact,  mais  jamais  sa  sensibilite  a  la  distension." 

After  withdrawing  the  catheter,  a  Jaques'  catheter  or  a  draining 
tube  is  tied  round  the  penis  to  prevent  the  escape  of  the  fluid. 

*  Loc.  supra  cit ,  p.  1 1 1 . 


SUPRA-PUBIC    LITHOTOMY.  753 

In  these  cases  of  irritable  bladder,  where  the  contents  are  ejected 
immediately  a  sound  is  introduced,  attention  must  be  paid  for  a  few 
days  previous  to  the  operation,  to  getting  the  bladder  accustomed  to 
gentle  distension,  steps  which  will  also  promote  an  antiseptic  condi- 
tion of  the  wound. 

C.  The  Operation  Itself. — The  pubes  being  shaved,  the  knees 
slightly  flexed,  and  the  shoulders  a  little  raised,  an  incision  is  made 
about  3  inches  long,  exactly  in  the  middle  line  and  ending  over  the 
upper  border  of  the  pubes.  The  subcataneous  fat,  often  plentiful  in 
amount,  having  been  divided  and  any  vessels  secured  with  Spencer 
Wells's  forceps,  the  linea  alba  is  identified,*  nicked,  and  slit  up  for 
2  or  3  inches.  The  transversalis  fascia  is  then  picked  iip  at  the 
lower  angle  of  the  wound  and  divided.  The  retractors  now  drawing 
the  edges  of  the  wound  well  apart,  a  layer  of  fat  often  abundant  and 
frequently  having  large  veins  in  it  will  next  come  into  view,  lying 
over  and  concealing  the  bladder.  This  must  be  torn  through  care- 
fully and  as  cleanly  as  possible  with  the  point  of  the  director.  Any 
veins  which  cross  the  wound  (and  a  transverse  branch  lies  often  just 
opposite  the  site  of  puncture  into  the  bladder),  should  be  secured 
with  forceps.  If  one  is  opened  at  this  stage  the  field  of  the  operation 
will  be  obscured  by  most  troublesome  haemorrhage. f  This  must  be 
arrested,  any  pressure-forceps  employed  acting  also  as  retractors ; 
prolonged  manipulation  in  arresting  haemorrhage  here  may  be  the 
cause  of  that  cellulitis  later  on  which  is  so  much  to  be  deprecated. 
The  anterior  surface  of  the  bladder  will  now  be  recognized  by  its 
pink  color,  the  fibres  of  the  detrusor  urin«e,  and  by  its  flu-ctuating 
under  the  finger.  Veins  often  are  met  with  again  here  on  the  bladder 
itself,  longitudinal,  transverse  and  occasionally  plexiform.  A  spot  on 
the  anterior  surface  of  the  bladder  having  been  chosen  just  ahove  the 
pubes,  it  is  punctured,  and  the  left  index  finger  at  once  introduced  to 
feel  for  the  stone.  This  is  best  removed  by  two  fingers,  or,  if  pre- 
ferred, by  forceps  and  scoop.  The  fingers,  if  successful,  have  the 
advantage  of  not  risking  any  injury  to  the  mucous  membrane.  As 
soon  as  the  stone  is  removed  and  the  bladder  thoroughly  explored, 

*  If,  instead  of  exactly  hitting  off  the  linea  alba  at  once,  the  snrgeon  exposes  fibres 
of  a  rectus  or  pyramidal  is,  he  should  go  straight  on  through  these  with  a  director. 
Any  prolonged  search  for  the  liiyea  alba  will  leave  frayed  fibrous  tissue,  whicli  will 
slougii  tediously,  and  become  coated  with  phosphatic  dejiosits  if  the  urine  be  am- 
moniacal. 

f  M.  Guyon  in  Iiis  second  case  met  with  most  profuse  haemorrhage:  "Nous 
essayames,  mais  assez  vainement,  a  nous  opposer  a  I'evahissement  de  toute  la  plaie  par 
nne  nappe  de  sang  sans  cesse  renouvel4e."  After  repeated  and  fruitless  attempts  to 
arrest  this  haemorrhage,  the  bladder  was  opened  and  the  stone  removed.  The  hferaor- 
rhage  ceased  entirely  on  the  removal  of  the  rectal  bag.  The  patient,  aged  sixtv-nine, 
died  with  purulent  infiltration  of  the  sub-peritoneaJ  connective  tissusL. 

48 


754  OPERATIONS  ON  THE  ABDOMEN. 

the  fluid  should  be  set  running  from  the  rectal  bag,  as  emptying  this 
takes  some  time.  Two  or  three  carbolized-silk  sutures  are  then  in- 
serted in  the  linea  alba  above,  and  cut  short,  and  three  or  four  more 
to  draw  the  edges  of  the  skin  together  (Fig.  125). 

Question  of  Sutures  in  the  Bladder. — I  have  not  used  these  in  any  of 
my  six  cases.  Whether  their  use  is  advisable  or  not  is  as  yet  unset- 
tled. I  am  very  strongly  of  opinion  that  they  should  never  be  used 
(i.)  where  there  is  cystitis — the  urine  was  ammoniacal  in  my  first 
five  cases  ;  (ii.)  where  the  stone  is  large ;  or  (iii.)  where  the  extrac- 
tion is  delayed  or  difficult.  I  cannot  but  think  that  sewing  up  the 
bladder  runs  a  great  risk.  If  sutures  are  used,  either  the  voluntary 
powers  of  expulsion  or  the  catheter  must  be  trusted  to.  If  the 
former  fail  and  the  latter  ha  trusted  to,  there  is  much  risk  of  the 
catheter  becoming  blocked,  and  of  the  lesser  evils  of  urethritis  and 
cystitis,  especially  with  the  delicate  mucous  membranes  of  children. 
In  either  case,  whether  the  instrument  is  left  in  or  not,  it  seems  to 
me  most  likely  that,  either  b_y  plugging  of  the  catheter  or  by  this  not 
being  passed  just  when  required,  some  urine,  perhaps  septic,  may  be 
forced  out  between  the  sutures  before  the  bladder  wound  is  firmly 
closed,  a  process  which  must  take  two  or  three  days.  If  this  extrava- 
sation should  take  place  deep  down  in  a  wound  like  this,  especially 
when  the  superficial  part  is  closed,  there  is  the  gravest  peril  of  a 
fatal  issue  from  purulent  infiltration  of  the  connective  tissue  of  the 
pelvis  and  abdominal  wall. 

I  do  not  wish  to  appear  to  forget  such  a  case  as  that  of  Dr.  Pilcher, 
who,  after  supra-pubic  lithotomy  in  an  adult,  sutured  the  bladder 
and  used  a  catheter  till  the  ninth  day.  The  patient  went  out  on  the 
eleventh,  and  was  shown  to  the  New  York  Medical  Society  on  the 
fourteenth  day,  "primary  union  having  taken  place  throughout  the 
whole  extent  of  the  wound,  without  unpleasant  symptoms  of  any 
kind."  Mr.  K.  W.  Parker  has  had  an  equally  successful  case  in  a 
child  aged  three.  But,  however  satisfactory  it  may  be  thus  to  shorten 
time  and  trouble,  I  cannot  but  think,  for  reasons  already  given,  that 
the  risk  run  is  greater  than  any  advantage  gained. 

A  few  words  may  be  said  here  about  the  peritoneum.  With  such 
distension  of  the  bladder  and  rectum  as  has  been  advised,  with  an 
incision  not  begun  too  high  up  and  carried  well  down  over  the  pubes, 
with  a  moderate  incision  into  the  bladder,  it  is  most  unlikely  that 
anything  will  be  seen  of  the  peritoneum.  It  may  be  very  indistinctly 
felt  at  the  upper  part  of  the  wound,  but  this  is  usually  all. 

If,  after  careful  distension  of  the  rectum  and  bladder  the  peri- 
toneum still  seems  to  encroach  too  far  upon  the  anterior  surface  of 
the  bladder,  it  may  be  pressed  upwards  and  held  out  of  the  way  by 
one  or  two  fingers  of  an  assistant,  or,  if  needful,  gently  peeled  upwards 


SUPKA-PUBIC    LITHOTOMY. 


r55 


Fig.  125. 


o£F  the  bladder  with  a  steel  director.*  In  elderly  people  with  lax 
tissues  and  large  stones  requiring  free  incisions,  the  peritoneum 
covered  with  its  fatty  tissue  is  more  likely  to  be  seen  rising  and  fall- 
ing in  the  upper  angle  of  the  wound. 

If,  what  is  most  unlikely  with  the  recent  improvements  in  the 
operation,  the  peritoneum  should  be  punctured  before  the  bladder 
is  opened,  the  puncture  should  be  pinched  up  and  tied  around  with 
fine  silk  or  chromic  gut ;  or  the  completion  of  the  operation  had  better, 
perhaps,  be  deferred,  or  lateral  lithotomy  performed. 

If  the  opening  is  made  after  the  bladder  is  opened,  the  surgeon 
must  decide,  according  to  the  amount  and  character  of  the  urine  which 
has  escaped,  between  suturing  the  opening  and  enlarging  it  upwards, 
so  as  to  thoroughly  sponge  out  or  cleanse  by  irrigation  with  a  2  per 
cent,  solution  of  boracic  acid,  the  peritoneal  cavity.  But  these  acci- 
dents are  most  unlikely  nowadays. 

D.  The  After-treatment. — 'A  little  iodoform  should  be  dusted  in 
and  around  the  wound  once  in  twenty-four  or  thirty-six  hours,  and 
iodoform  or  sal-alembroth  gauze  and  boracic  lint  applied  externally. 
The  trochanteric  and  gluteal  regions  should 
be  kept  well  smeared  with  eucalyptus  oint- 
ment. If  the  above  dressi^igs  are  kept  in 
position  with  a  many-tailed  bandage,  it  only 
takes  a  few  minutes  to  renew  them.  This 
will  be  necessary,  at  first,  every  three  or  four 
hours;  in  fact,  the  surgeon  who  wishes  to 
practice  this  operation  successfully  will  find 
that  the  local  after-treatment  will  give  him  a 
good  deal  more  trouble  than  is  usually  be- 
stowed on  a  case  of  lateral  lithotomy,  where 
the  patient  simply  lies  on  a  mackintosh  and 
draw-sheet,  and  perhaps  a  lithotomy  sponge, 
with  his  knees  tied  together  for  the  first  few 
hours. 

It  is  only  by  keeping  the  wound  aseptic  by 
the  frequent  change  of  dressings,  tlie  use,  if 
needful,  of  some  such  fluid  as  that  given  at 
p.  752,  and  by  turning  the  patient  on  his  side  for  three  hours  at  a  time, 
after  the  first  twelve  hours,  as  recommended  by  Sir  H.  Thompson,  that 
the  risks  of  cellulitis  and  extravasation  can  be  prevented,  the  two  points 


Supra-pubic  lithotomy  iuci- 
sion,  seven  days  after  the  opera- 
tion. Only  the  upper  part  of  the 
wound  was  sutured. 


*  At  the  Congress  of  German  Snrgeons  in  1886,  Gussenbauer,  Sonnenberg,  and 
Kramer  mentioned  cases  in  which  the  peritoneum  was  found  adlierent  to  the  sym- 
physis. In  one  case  it  was  opened  witii  fatal  results;  in  another,  the  opening  was 
sewn  up  and  the  peritoneum  safely  separated  from  the  pubes. 


756  OPERATIONS  ON  THE  ABDOMEN. 

in  which  this  operation  is  said,  rightly  or  wrongly,  to  be  inferior  to 
the  lateral  method. 

I  have  now  operated  by  this  method  six  times  in  the  last  two  years, 
the  patients  ranging  from  three  to  sixty-two  years.  None  of  the  stones 
were  large.  In  two  they  were  multiple.  In  the  first  five  the  urine 
was  alkaline  and  foul.  One  case  was  fatal — the  sixth,  a  lad  of  nine- 
teen, an  orphan,  in  wretched  condition  of  body,  and  in  much  misery 
from  pain.  Perhaps  I  should  have  done  more  wisely  to  have  waited 
longer,  in  order  to  feed  him  up  before  operating.  His  pain,  however, 
was  so  severe  that  I  operated  a  week  after  his  admission  into  the  hos- 
pital. He  did  excellently  for  forty-eight  hours,  then  symptoms  of 
pelvic  cellulitis  set  in,  proving  fatal  on  the  fourth  day. 

While  on  some  points  connected  with  the  operation  my  mind 
remains  open,  I  am  strongly  of  opinion  that,  with  carefulness,  it  is  a 
safer  operation  than  the  lateral  method  for  those  who  only  perform 
lithotomy  occasionally,  and  for  large  stones— e.f/.,  over  3  oz.  I  do  not 
think  any  benefit  is  to  be  gained  by  substituting  it  for  the  lateral  in 
the  case  of  children. 

MEDIAN  LITHOTOMY. 
Disadvantages. 

1.  It  gives  very  little  room,  and  is  unsuited  to  any  save  the  smallest 
stones. 

2.  The  wound  being  small,  the  surgeon  cannot  bury  his  knuckles 
in  it  or  reach  the  bladder  as  easily  as  in  the  case  of  the  larger  lateral 
wound  (Cadge). 

3.  The  rectum  on  the  one  hand,  and  the  bulb  on  the  other,  are  in 
greater  danger  than  by  the  lateral  method  (Cadge). 

4.  Troublesome  bleeding  is  more  frequent  (Cadge). 

Mr.  Cadge,  having  operated  on  fifty  or  sixty  cases  by  the  median 
method,  has  given  it  up  for  the  above  reasons,  and  also  because  his 
mortality  has  been  rather  higher. 

Advantages. — Recovery  is  often  extremely  rapid ;  the  urine 
quickly  resumes  its  natural  route ;  and  the  wound,  instead  of  gaping 
and  healing  slowly  as  the  lateral  wound  does,  heals  almost  by  first 
intention. 

The  above  do  not,  however,  compensate,  in  Mr.  Cadge's  opinion,  for 
the  disadvantages.  He  would  avoid  it,  especially  in  children,  in  whom 
it  is  by  some  preferred,  as  in  them  a  free  incision  is  necessary  to  facil- 
itate the  passing  of  the  finger  into  the  bladder,  while  here  the  limit 
of  space  for  the  knife  is  ver}^  small  indeed. 

The  operation  is  suited  for  prostatic  calculi,  but,  if  these  are  asso- 
ciated with  any  larger  one  in  the  bladder,  the  surgeon  must  either 
crush  this  before  he  can  extract  it  through  his  small  incision,  or  per- 
form a  supra-pubic  operation. 


MEDIAN   LITHOTOMY.  757 

Operation. — If  a  curved  *  staff  be  used,  one  with  a  wide  groove  is 
chosen,  and  passed  and  held  with  its  handle  inclined  towards  the 
umbilicus  (p.  742),  the  patient  being  in  lithotomy  position.  The  sur- 
geon passes  his  left  forefinger  into  the  rectum  so  as  to  steady  with  its 
tip  the  staff  in  the  membranous  urethra  and  also  to  guard  the  rectum 
from  puncture,  while  at  the  same  time  note  is  taken  of  the  depth  of 
tissues  between  the  knife  and  the  finger.  A  straight  and  very  sharp 
bistoury  is  then  pushed,  with  its  back  downwards,  through  the  skin 
i  inch  above  the  anus  straight  on  into  the  groove  in  the  staff,  which 
is  now  held  well  hooked  up  against  the  pubes.  The  knife,  having 
distinctly  exposed  the  groove,  is  pushed  a  little  onwards  so  as  to  nick 
the  apex  of  the  prostate,  and  next,  as  it  is  withdrawn,  it  is  carried 
upwards  in  the  raphe  so  as  to  divide  the  soft  parts  for  1  inch  or  more 
according  to  the  size  of  the  stone.  The  finger  would  now  be  passed 
into  the  bladder  and  the  staff  withdrawn.  -As,  however,  the  staff 
occupies  too  much  room  in  the  limited  wound  to  allow  of  this,  a 
director  is  passed  in  along  the  groove,  the  stafF  withdrawn,  and  then 
the  finger  introduced  along  the  director  through  the  neck  of  the  blad- 
der.    This  is  dilated  sufficiently,  and  the  scoop  or  forceps  introduced. 

Some  surgeons  prefer  to  make  the  incision  from  above  downwards, 
but  cutting  from  below  upwards  would  seem  better  to  protect  the 
bowel. 

If  a  straight  staff  be  used,  the  surgeon,  introducing  his  knife  as 
above,  and  having  cut  upon  the  staff  distinctly  both  to  himself  and 
the  assistant  who  is  holding  it,  takes  it  into  his  left  hand,  and,  having 
brought  it  down  into  an  oblique  position,  runs  his  bistoury  along  the 
groove  so  as  to  nick  the  jjrostate;  the  enlargement  of  the  wound  and 
the  rest  of  the  operation  are  conducted  as  above. 

Complications  and  Causes  of  Death  after  Lithotomy. 

1.  Shock. — This  is  rarely  severe,  save  in  patients  much  pulled  down, 
and  after  prolonged  operations.  Children,  as  a  rule,  however  reduced,! 
rall}^  well  after  the  operation  (Sir  J.  Paget,  Clin.  Essays,  p.  404). 

2.  Hoemorrhage. — If  milder  methods  fail,  this  is  best  met  by  plug- 
ging the  wound  with  the  umbrella-plug,  or  by  leaving  in  situ  a  pair  of 
Spencer  Wells's  forceps,  which  will  also  aid  the  drainage. 

3.  Pelvic  cellulitis. — This,  the  most  frequent  cause  of  death,  is  due 
either  to  extravasation  of  urine,  probably  septic,  or  to  laceration  of 

*  Mr.  Erichsen  recommends  a  rectangular  staff,  the  angle  of  which  rests  against  the 
apex  of  the  prostate,  and  is  thus  much  easier  to  find  in  the  perineum.  This  special 
staff" is,  however,  often  difficult  to  introduce,  and  a  curved  one,  held  so  as  to  project  its 
curve  in  the  perineum,  will  be  easily  found. 

t  Occasionally,  however,  even  nowadays,  where  the  history  is  of  long  standing,  and 
the  kidneys  much  impaired,  they  are  too  f\\r  gone  for  operation.  See  a  case  by  Mr. 
Hutchinson  {Clin.  Surg.,  pi.  Ixxvi.  vol.  ii.  p.  126). 


758  OPERATIONS    ON    THE    ABDOMEN. 

the  deep  parts,  or   both.     It   usually   comes   on  within    forty-eight 
hours. 

4.  Peritonitis. — Usually  combined  with  the  above. 

5.  Septic  complications. — Septicaemia  may  occur  early  with  pelvic 
cellulitis.     Pyffimia,  on  the  other  hand,  may  come  on  later. 

6.  Surgical  kidney. 

7.  Retention  of  urine. — Common  enough  a  few  days  after  from 
swelling  of  the  parts.     Rarely  more  serious. 

8.  Suppression  of  urine. 

9.  A  sloughy  phosphatic  state  of  the  wound. 

10.  Sloughing  of  the  rectum  (p.  746). 

11.  Cystitis. — Rare. 

12.  Epididymitis. 

13.  Such  causes  as  tetanus. 

Later  complications,  rare,  but  troublesome  : 

14.  Fistula. 

15.  Incontinence. 

16.  Sterility. 

LITHOTRITY-OPERATION  WITH  SEVERAL  SITTINGS 
—RAPID  OPERATION  WITH  ONE  SITTING  AND 
EVACUATION.— LITHOLAPAXY. 

Choice  of  Operation — Lithotrity  or  Lithotomy. — It  is  hoped 
that  the  following  points,  while  they  do  not  in  the  least  exhaust  the 
subject,  will  be  found  of  practical  assistance, 

1.  Amount  of  experience  of  the  surgeon. — Every  attempt  should  be 
made  to  become  familiar  with  the  use  of  the  instruments,  botli  outside 
the  body  and  also  bypassing  a  lithotrite  for  examination  of  a  calculus 
whenever  one  is  felt  on  sounding.  No  surgeon  who  has  not  had  abun- 
dant opportunities  of  practicing  the  needful  manipulations  will  do 
wisely  in  attempting  to  crush  a  hard  stone  which  weighs  an  ounce. 

2.  Size,  kind,  and  number  of  stones. — As  to  size,  up  to  1  oz.  or  Ih 
oz.  it  is  probable  that,  with  the  majority  of  stones,  in  fairly  practiced 
hands  lithotrity  is  immensely  superior  to  lithotomy  as  far  as  imme- 
diate mortality  is  concerned.  I  use  the  term  ''  immediate  "  advisedly, 
because  of  the  more  frequent  recurrence,  with  its  results,  after  lithotrity, 
and  would  refer  my  readers  to  the  remarks  on  this  point  at  p.  761. 
With  calculi  from  1^  to  3  oz.,  to  quote  Mr.  Cadge's  words,  "it  yet 
remains  to  be  seen  whether  lithotomy  by  any  method  can  be  applied 
with  more  safety  and  success  than  lithotrity." 

The  difficulty  of  a  decision  sometimes  met  with  here  is  well  ex- 
pressed by  the  words  of  Sir  W.  Fergusson,  that  the  greater  is  the 
experience  of  the  surgeon  the  greater  will  sometimes  be  his  doubt. 

Sir  H.  Thompson,  speaking  of  hard  calculi  and  litholapaxy  {R.C.S. 


LITHOTRITY — LITHOLAPAXY.  759 

Led.,  1884,  p.  127),  states  that  the  largest  he  has  dealt  with  weighed  21 
oz.,  the  operation  lasting  seventy  minutes.  As  the  outcome  of  a  ver}'^ 
especial  experience,  the  same  Lectures  show  (p.  138)  that  with  Sir  H. 
Thompson  the  proportion  of  lithotomy  to  lithotrity  has  fallen  from  1 
in  4  to  1  in  30. 

More  important  than  the  size  of  the  stone  is  its  composition.  There 
is,  of  course,  no  comparison  between  a  pure  lithic  acid  or  oxalate  of 
lime  stone  on  the  one  hand  and  an  alternating  stone  with  a  good  deal 
of  phosphate  or  urates  in  its  composition,  as  a  test  of  skill  and  en- 
durance both  on  the  part  of  the  surgeon  and  his  instruments.  Dr. 
Kingston,*  of  Montreal,  points  out  that  sometimes  the  apparent  soft- 
ness of  a  stone  is  most  misleading.  Having  found  an  enormous  stone 
in  a  patient,  he  employed  lithotrity,  as  the  stone  seemed  soft.  After 
getting  away  a  large  quantity  of  phosphatic  matter,  he  was  driven  to 
perform  lithotomy,  and  removed,  by  the  lateral  method,  a  calculus 
weighing  over  5  oz.,  consisting  mainly  of  oxalate  of  lime  and  uric 
acid. 

There  are  several  fallacies  in  addition  to  the  above  in  gauging  the 
size  and  number  of  calculi.  Thus  the  lithotrite  may  again  and  again 
seize  a  stone  whicli  only  weighs  2  oz.  in  its  long  diameter,  if  flattened, 
of  2  inches.  Testing  by  passing  a  staff  around  or  rubbing  it  over  a 
calculus  is  often  most  fallacious,  and  examining  per  rectum  may,  if  the 
bladder  be  thickened,  give  evidence  of  a  stone  apparently  much  larger 
than  it  really  is.  Mr.  Cadge  {he.  supra  dt.)  points  out  a  fallacy  with 
regard  to  multiple  stones.  "  When  more  than  one  stone  is  present,  it  is 
customary  to  seize  one,  fix  it  in  the  instrument,  and  proceed  to  sound 
afresh ;  this,  however,  may  mislead,  for  a  stone,  having  been  grasped 
by  the  tips  of  the  blades  and  moved  about  in  the  bladder,  Avill  some- 
times rotate  a  little  in  the  blades  of  the  lithotrite  and  communicate  a 
grating  feel  to  the  hand  which  is  very  like  touching  a  second  stone." 

3.  Condition  of  the  urethra. — Two  points  have  to  be  considered 
here — (a)  how  far  will  the  urethra  admit  instruments,  i.e.,  how  f;ir  is 
its  canal  normal  or  diminished  by  stricture;  (b)  how  far,  even  if 
normal  in  calibre,  will  the  urethra  tolerate  instruments.  With  regard 
to  the  first,  a  stricture,  if  admitting  of  dilatation,  is  not  an  obstacle  to 
lithotrity ;  on  the  other  hand,  an  old  stricture  with  surrounding  indu- 
ration and  fistulae,  or  a  less  severe  form  which  produces  rigors  and 
fever  at  each  attempt  at  dilatation,  are  best  submitted  to  lithotomy, 
which  gives  the  best  chance  for  the  stone,  and  at  the  same  time  offers 
the  much  needed  relief  of  rest  to  the  stricture.  Mr.  Cadge  gives  the 
following  practical  hint  in  these  cases  of  stone  combined  with  stricture: 
"Sometimes  a  stone  is  detected  in  the  urethra  behind  the  stricture, as 

*  Intern.  Encycl.  of  Surg.,vo\.  v\.  p.  311,  in  his  article  on  Lithotrity. 


760  OPERATIONS    ON   THE    ABDOME^;. 

well  us  one  or  more  in  the  bladder,  or  it  may  be  partly  in  the  bladder 
and  partly  in  the  urethra,  and  in  these  cases  median  lithotomy  will 
not  only  remove  the  stone,  but  may  go  far  to  remedy  the  stricture  by 
external  division." 

With  regard  to  an  irritable  urethra,  i.e.,  one  without  a  stricture  and 
only  admitting  instruments  with  the  aid  of  ana3Sthetics — the  chief 
points  to  consider  are  the  size  of  the  stone  and  the  ability  of  the  sur- 
geon to  deal  with  it  by  litholapaxy.  If  the  calculus  cannot  be  evacu- 
ated at  once,  or  requires  m.ore  than  one  sitting,  lithotomy  should  be 
preferred,  owing  to  the  results  of  the  passage  of  instruments  and  pro- 
longed voiding  of  fragments. 

4.  Condition  of  tlie  prostate. — An  enlarged  prostate  is  of  great  im- 
portance, not  only  from  its  power  of  obstructing  the  operation,  but 
from  the  changes  which  it  brings  about  in  the  bladder.  Thus  it  in- 
terferes with  the  efficient  use  of  instruments,  the  picking  up  of  a  stone 
even  with  blades  reversed,  and  the  finding  of  the  last  fragment.  Again, 
the  use  of  the  lithotrite  and  the  passage  of  evacuating  tubes  readily 
lead  to  haemorrhage,  and  this  again  by  clots  prevents  the  free  and  easy 
use  of  the  evacuator.  Later  on,  phosphatic  deposit,  imperfect  evacua- 
tion, residual  urine,  and  recurrence  of  stone  symi:>toms  are  all  frequent 
accompaniments  of  enlarged  prostate. 

5.  Condition  of  the  bladder. — Formerly  it  was  held  needful  to 
operate  with  several  ounces  of  fluid  in  the  bladder,  and  some  sug- 
gested to  draw  off  the  urine  and  inject  8  or  10  oz.  of  fluid.  This 
amount  has  now  been  reduced  to  something  more  like  4  or  6  oz.  As, 
if  the  urine  is  healthy,  no  fluid  is  more  suited  to  the  bladder,  the  sur 
geon  should  content  himself  with  following  Sir  H.  Thompson,  and 
"  ask  the  patient  to  retain  his  urine  for  a  little  less  than  his  accustomed 
period  before  the  sitting ;  that  is,  if  he  is  naturally  able  to  retain  his 
urine  for  about  an  hour,  he  is  requested  to  pass  it  forty  minutes  before 
the  time  of  the  visit." 

Some  other  changes  in  the  bladder  require  mention,  (a)  Saccula- 
tion pouches  or  sacs,  whether  mere  hollows  behind  or  at  the  sides  of 
an  enlarged  prostate,  or  hernial  protrusions  of  the  mucous  membrane 
between  the  muscular  fibres,  may  be  the  starting-point  of  calculus  by 
entangling  debris  or  tiny  fragments.  In  Mr.  Cadge's  words:  "The 
imprisoned  fragment  first  fills  up  the  cyst,  then,  by  continual  accretion 
of  phosphates,  it  grows  up  into  the  bladder  like  a  mushroom,  and  i^ 
probably  again  and  again  nibbled  off  by  the  lithotrite,  each  time  with 
temporary  benefit,  until  the  patient  dies,  worn  out  with  chronic  cystitis 
and  pyelitis."  Mr.  Cadge  goes  on  to  say  :  "  By  turning  the  aperture 
of  the  evacuating  catheter  towards  these  pouches,  and  by  the  free  use 
of  the  aspirator  in  all  directions,  the  fragments  may  be  washed  out  of 
them  and  all  removed,  but  it  cannot  be  denied  that  it  is  always  a  se- 


LITHOTRITY — LITHOLAPAXY.  761 

rious  matter  to  shatter  a  stone  into  innumerable  fragments  in  a  bladder 
of  this  description."  {b)  Atony,  whether  with  or  without  an  enlarged 
prostate.  The  importance  of  this  is  obvious,  as  tending  to  recurrence 
of  stone  by  some  small  fragments  not  being  expelled  in  spite  of  the 
vigorous  use  of  the  aspirator,  and  also  to  cystitis  from  imperfect 
emptying  of  the  bladder. 

6.  Condition  of  the  kidneys. — Here  I  may  again  quote  a  veteran's 
opinion,  that  of  Mr.  Cadge :  ''  What  is  to  be  said  of  stone  complicated 
with  kidney  disease,  such  as  albuminuria  and  chronic  pyelitis  and 
atrophy  ?  In  these  cases  all  operations  are  fraught  with  danger,  but 
it  is  probable  that  the  least  danger  will  be  met  with  from  a  carefully 
conducted  one-sitting  lithotrity.  So,  too,  in  those  cases  of  constitutional 
disease  combined  with  stone,  such  as  diabetes,  tabes,  and  other  spine 
disease,  it  will  be  well  to  avoid  the  shock  and  htiemorrhage  of  lithotomy, 
and  proceed,  if  any  surgical  proceeding  is  allowable,  by  lithotrity." 
The  surgeon,  in  considering  an  operation  in  any  of  the  above  diseases, 
will  weigh  well  the  size  of  the  stone,  his  ability  to  cope  with  it  at  one 
sitting,  and  the  amount  of  suffering  which  it  causes  the  patient. 

7.  Age. — Here,  especially,  age  is  not  to  be  reckoned  by  years  alone. 
Recurrence. — As  no  one,  to  my  knowledge,  has  spoken  out  on 

this  subject  with  such  helpful  candor  as  Mr.  Cadge,  with  his  experi- 
ence of  300  cases  of  stone,  I  make  no  apology  for  quoting  once  more 
from  his  writings.*  "  Although  the  immediate  and  dii'cct  mortality 
of  lithotrity  is  small,  the  recurrence  of  stone  is  lamentably  frequent. 
In  my  own  list  of  133  cases,  there  were  18  in  which  recurrence,  one  or 
more  times,  took  place,  being  about  1  in  7.  Sir  H.  Thompson,  with  a 
much  larger  number  of  cases,  gives  about  the  same  proportion.  I  am 
disposed  to  infer,  however,  that  recurrence  is  more  frequent  even  than 
this,  because  it  is  not  likely  that  all  who  get  relapse  apply  to  the  same 
surgeon  again.  Living,  as  I  do,  in  a  local  centre,  and  drawing  cases 
chiefly  from  a  limited  area,  I  am  probably  more  able  to  trace,  and 
more  called  on  to  treat,  those  who  sutler  a  second  and  third  time, than 
he  who  lives  in  the  metropolis  and  draws  his  cases  from  great  distances. 
Patients  may,  and  frequently  do,  apply  to  the  same  operator  once  or 
twice ;  but,  after  a  time,  they  either  apply  to  their  own  surgeon,  or 
they  decline  further  treatment,  and  too  often  their  subsequent  history 
is  one  of  painful  endurance  of  chronic  bladder  disease  and  gradual 
exhaustion.  If,  moreover,  there  be  added  to  the  list  those  numerous 
cases  of  phosphatic  deposit  or  concretions  so  frequently  noticed  after 
lithotrity,  the  relapses  would,  I  believe,  reach  to  nearly  20  per  cent. 
This  seems  a  heavy  indictment  to  bring  against  lithotrity,  but  I  am 
afraid  there  is  no  gainsaying  it;  and,  if  so,  it  would  be  wrong  to  pass 

*  Brit.  Med.  Journ.,  July  3,  1886. 


762  OPERATIONS  ON  THE  ABDOMEN. 

it  over  or  make  light  of  it.  Many  of  these  relapses  might  be  prevented 
if  the  patients  would  observe  directions  and  persevere  with  treatment. 
It  certainl}^  is  so  with  the  unenlightened  and  uncomplaining  hospital 
patient.  Feeling  himself  well,  or  what  he  considers  well,  he  goes  to 
his  work,  and  neglects  the  use  of  the  catheter  and  other  means;  and, 
instead  of  returning  in  a  month  or  so  to  have  his  cure  certified,  or  a 
minute  remaining  fragment  removed,  he  toils  away  as  long  as  he  can, 
and  returns,  perhaps  in  a  year  or  two,  with  a  fresh  uric-acid  stone,  or 
with  chronic  cystitis  and  a  phosphatic  one.  The  educated,  sensitive, 
private  patient,  on  the  other  hand,  will  watch  his  symptoms  narrowly, 
and  return  if  the   slightest  indication  of  the   old  mischief  should 

reappear This  frequent  recurrence  must  be  due  either  (1)  to 

the  descent  of  a  fresh  stone  from  the  kidneys,  or  (2)  to  a  fragment  of 
stone  having  been  left  at  the  first  operation.  As  to  the  descent  of  a 
fresh  stone :  there  can,  of  course,  be  no  doubt  as  to  the  occasional 
occurrence  of  this  cause,  just  as  we  see  it  occur  after  lithotomy.  The 
bladder  being  entirely  cleared  of  stone,  there  will  be  the  same  liability 
to  the  descent  of  a  fresh  renal  calculus  after  one  operation  as  after  the 
other.  What,  then,  let  me  ask,  is  the  fact  as  to  lithotomy?  I  have 
already  shown  that  there  were  only  21  cases  out  of  more  than  1000  of 
lithotomy  at  the  Norwich  Hospital  in  Avhich  recurrence  was  clearly 
traced  to  perfectly  fresh  formations  coming,  like  the  first,  from  the 
kidney,  or  about  1  in  50 ;  whereas,  in  Sir  H.  Thompson's  list  of  about 
600  persons  treated  by  lithotrity,  he  mentions  61  cases  in  which  he 
operated  twice,  9  three  times,  3  four  times,  and  2  five  tim^s — 75  in  all, 
or  about  1  in  8.  The  inference  from  these  data  seems  to  me  to  be  in- 
evitable that  relapse  of  stone  after  lithotrity  is  chiefly  due  to  other 
causes  than  the  descent  of  a  fresh  stone.  To  my  thinking,  the  majority 
of  recurrences  is  caused  by  the  great  difficulty  in  ensuring  the  complete 
removal  of  all  the  debris;  I  have  already  referred  to  this  in  old  per- 
sons with  enlarged  prostate  and  feeble  atonic  bladder,  and  it  is  this 
class  of  patients  who  are  especially  liable  to  relapse."  Mr.  Cadge  goes 
on  to  show  that  the  tendency  to  phosphatic  deposit  after  lithotrity  is 
not  due  to  vesical  incompetence  and  residual  urine  alone  without 
some  overlooked  fragment,  and  that  the  improved  method  with  re- 
peated washings  will  still  fail  to  discover  a  last  fragment  in  some 
bladders. 

Operation  (Fig.  126). — The  preparatory  treatment  has  been  much 
simplified.  It  is  now  recognized  that  the  best  course  is  to  remove 
the  stone:  previous  passage  of  sounds,  and  injections  of  the  bladder,* 

*  The  amoiint  of  urine  to  be  held,  in  most  cases,  has  already  been  mentioned  (p. 
760). 


LITHOTRITY — LITHOLAPAXY.  763 

are  now  but  little  used.     A  few  days'  rest,  bland  unirritating  liquid 
diet,  mild  aperients,  and  securing  sleep  are  the  chief  indications. 

The  instruments  required  will  be  gathered  from  the  following 
account.  The  patient  being  ana?sthetized  and  lying  on  a  firm  couch 
or  mattress  close  to  the  right  side  of  the  bed  or  table,  with  his  pelvis 
raised,  and  body  and  limbs  well  protected  from  chill,  the  surgeon, 
standing  on  the  right  side  with  his  instruments  close  to  him,  intro- 
duces his  lithotrite.  In  doing  this  care  must  be  taken  not  to  get  the 
blades  hitched  either  just  in  front  of  the  triangular  ligament  or  in  the 
roof  of  the  prostatic  urethra.  This  will  be  secured  by  not  depressing 
the  instrument  till  very  late — in  fact,  not  till  it  is  just  about  to  enter 
the  bladder.  The  instrument,  well  warmed  and  oiled,  is  held  at  first 
horizontally  over  the  groin  or  abdomen,  the  penis  being  drawn  over 
it,  the  shaft  being  all  the  time  gradually  brought  into  the  vertical 
position  as  the  instrument  finds  its  way  by  its  own  weight  into  the 
bulbous,  membranous,  and  prostatic  urethra.  Now,  and  not  before, 
the  handle  is  somewhat  depressed,  and  the  instrument  glides  quickly 
into  the  cavity  of  the  bladder.  If  the  prostatic  urethra  is  enlarged 
and  lengthened,  the  surgeon  may  think  that  he  has  reached  the 
bladder,  but  the  fact  that  the  gentlest  lateral  movement  of  the  litho- 
trite is  interfered  with  will  show  him  his  mistake.  Pressure  with  the 
instrument  is  alone  allowable  at  the  meatus;  some  rotation  maybe 
called  for  in  guiding  the  instrument  through  the  triangular  ligament 
or  past  an  enlarged  prostate.  In  this  latter  case  also  the  handles 
must  be  further  depressed,  and  a  finger  in  the  rectum  may  give  help. 
When  the  lithotrite  has  entered  the  bladder  it  should  be  allowed  to 
slide,  very  gently,  down  the  trigone,  being  now  held  very  lightly  so 
as  at  once  to  detect  the  site  of  the  stone,  which  it  now  often  touches, 
but  must  not  displace. 

If  the  stone  is  felt  on  one  side,  the  instrument  is  gently  turned  to 
the  opposite  one,  opened,  and  then  turned  towards  the  stone.  If  it 
be  not  felt,  the  handles  of  the  instruments  being  slightly  raised,  and 
the  blades  very  gently  depressed  and  then  opened,  the  stone  will  often 
drop  into  them. 

■  If  this  fail,  the  instrument  is  turned,  open,  first  obliquely,  then 
more  horizontally,  first  to  the  one  side,  then  to  the  other.  In  the 
event  of  the  stone  still  eluding  the  lithotrite,  which  is  most  unlikely, 
it  should  be  sought  for  with  blades  depressed.  To  effect  this,  the 
blades,  closed,  are  raised  off  the  bladder  floor  by  depression  of  the 
handle,  carefully  reversed,  and  then  depressed  again  so  as  to  sweep 
lightly  over  the  floor.  They  are  then  gently  opened  and  closed, 
vertically  first  and  then  obliquely,  so  as  to  complete  the  examination. 
During  the  above,  the  following  points  must  ever  be  borne  in 
mind  : 


764  OPERATIONS  ON  THE  ABDOMEN. 

(a)  The  handle  and  shaft  of  the  lithotrite  are  to  be  kept  as  steady- 
as  possible,  so  as  not  to  jar  the  sensitive  neck  of  the  bladder  need- 
lessly. 

(h)  All  movements  are  to  be  executed  at  or  beyond  the  centre  of  the 
vesical  cavity,  the  proper  area  of  operating,  without  hurry,  rapid 
movement,*  or  any  other  which  partakes  of  the  nature  of  a  jerk  or 
concussion  (Sir  H.  Thompson,  loc.siqymcU.,  p.  296). 

The  male  blade  is  never  to  be  brought  into  contact  with  the  neck 
of  the  bladder,  unless  this  is  rendered  necessary  by  the  position  of 
the  stone. 

The  stone  being  seized  by  one  of  the  above  manoeuvres,  the  buttonf 
moved,  and  the  screw  connected — the  screw  is  gradually  turned  at 
first  to  make  the  jaws  bite,  since  a  sharp  turn  at  this  time  may  drive 
the  stone  out  either  to  right  or  left — the  calculus  is  then  carried  to  the 
centre  of  the  cavity,  which  will  show  whether  a  fold  of  mucous  mem- 
brane has  been  seized.  As  the  screw  is  applied  more  and  more  forci- 
bly, one  or  other  of  the  following  will  be  noticed.  If  not  well  caught, 
and  if  hard,  it  will  be  pushed  out  of  the  jaws ;  if  a  hard  calculus  and 
well  gripped,  it  is  felt  to  split  into  fragments;  if  soft,  and  held,  it 
crumbles  down.  If  extremely  hard,  as  a  pure  lithic  acid  or  oxalate, 
any  attempt  at  advancing  the  screw  is  met  by  this  distinctly  recoiling 
instead  of  advancing.  Each  surgeon  must  now  decide  for  himself, 
according  to  his  knowledge  of  his  instruments  and  reliance  on  his 
power  to  deal  with  large  hard  fragments,  whether  to  continue  or  at 
once  to  perform  lithotomy.  If  he  continue,  the  resistance  will  be  felt 
to  give  way,  in  the  case  of  a  very  hard  stone,  by  a  sudden  sharp  crack  ; 
in  one  less  hard,  more  gradually.  In  overcoming  much  resistance 
the  surgeon  eitlier  screws  up  the  male  blade  as  hard  as  he  can  and 
keeps  it  so,  or,  having  gently  unscrewed  it  a  little,  screws  it  up  again 
with  a  series  of  light  jerks  so  as  to  communicate  blows  to  the  stone. 
Cracking  of  the  stone  having  taken  place,  the  fragments  will  usually 
fall  close  to  the  original  site.  Thus  the  lithotrite  has  only  to  be  kept 
as  immovable  as  possible  to  ensure,  on  drawing  out  and  again  closing 
the  male  blade,  the  seizure  of  a  fragment.^  This  is  crushed,  and  the 
process  repeated  again  and  again  till  sufficient  debris  is  formed.  The 
lithotrite  is  then  withdrawn  firmly  screwed  up. 


*  "Rnpid  movements  produce  currents  which  keep  the  stone  more  or  less  in 
motion,  so  that  it  is  less  easily  seized  than  when  the  surrounding  fluid  is  in  a  state  of 
rest"  (Thompson). 

f  In  tliis  respect  Prof.  Bigelow's  lithotrite  seems  inferior  to  Sir  H.  Thompson's,  the 
working  of  the  hutton  in  the  latter  being  smoother  and  less  vibrating. 

X  It  is  not  always  easy  to  distinguish  between  a  piece  of  soft  stone  enveloped  in 
concrete  mucus  and  the  lining  membrane  of  tlie  bladder. 


LITHOTRITY — LITHOLAPAXY.  765 

An  evacuating  straight  or  curved*  tube,  No.  16  for  a  stone  of  mod- 
erate size,  and  18  for  a  large  one,  is  then  introduced,  the  evacuator, 
filled t  with  a  warm  solution  of  boracic  acid  or  dilute  Thompson's 
fluid  (p.  752).  is  connected,  the  meatus  being  first  incised  with  a 
narrow  probe-pointed  bistoury  downwards  by  the  side  of  the  fraenum 
if  needful.  While  his  left  hand  supports  the  evacuator,  with  his  right 
the  surgeon  gently  but  quickly  squeezes  the  bag  with  sufficient  force 
to  send  in  about  2  oz.  of  fluid.  On  relaxing  the  pressure  an  outward 
current  takes  place,  bringing  with  it  crushed  fragments.  Sir  H. 
Thompson  recommends  that,  after  the  bag  has  expanded  and  the 
current  apparently  ceased,  the  surgeon  should  wait  a  few  seconds, 
"as  at  that  precise  time  it  is  quite  common  for  one  or  two  of  the 
larger  fragments  to  drop  into  the  receiver  which  would  have  been 
driven  back  perhaps  by  too  rapidly  resuming  the  pressure." 

If,  after  several  washings,  the  outflow  stops,  and  the  bag  no  longer 
expands,  the  end  of  the  evacuator  is  blocked  either  by  a  fragment  of 
stone,  or  a  small  calculus,  a  clot  of  blood,  or  the  mucous  membrane 
of  the  bladder.  If  it  be  a  fragment,  as  is  usually  the  case,  or  a  clot, 
dislodgment  may  be  eff'ected  by  sending  in  quickly  a  gush  of  fluid,  or 
by  the  use  of  a  gum-elastic  stylet,  after  unscrewing  the  tube.  Impact 
of  the  bladder  generally  takes  place  when  a  curved  evacuator  is  turned 
upwards,  and  when  the  bladder  is  empty.  The  sensation  given  may 
be  a  kind  of  flap,  simulating  the  click  of  a  fragment;  more  often  it  is 
a  dull  vibrating  thud,  easily  recognized.  More  fluid  must  be  at  once 
injected. 

If  a  large  fragment  is  felt  striking  against  the  tube,  or  if  the  surgeon 
is  certain  that  several  good-sized  fragments  remain,  he  removes  the 
tube  and  evacuator,  and,  while  an  assistant  Avithdraws  the  blood- 
stained fluid  and  fragments  and  re-charges  the  evacuator,  he  intro- 
duces a  small  lithotrite  and  crushes  up  sufficient  debris  to  go  on  again 
with  the  washings. 

All  the  time  the  surgeon  must  keep  before  his  eyes  a  mental  picture 
of-  the  interior  of  the  bladder,  perhaps  diseased,  the  ureters,  perhaps 

*  The  tube,  if  curved,  should  he  held  downwards  at  first,  but  not  quite  on  the  bladder 
floor;  then  to  one  side  or  the  other;  then  upwards,  washings  being  carried  on  at  the 
time  that  these  movements  are  made.  A  straight  tube  should  lie  with  its  orifice  just 
within  the  neck  of  the  bladder. 

t  Dr.  Keyes  (Intern.  Encycl.  of  Surg.,  vol.  vi.  p.  244)  gives  this  precaution  as  to 
getting  rid  of  air  entirely ;  "  The  urine,  having  trickled  away  through  the  tube, 
leaves  the  latter  full  of  air,  an  element  fatal  to  nicety  of  washing.  This  air  may  be 
disposed  of  most  simply.  The  tube  is  withdrawn  until  its  eye  is  in  the  prostatic 
sinus,  the  washing-bottle  is  attached,  and  the  stop-cock  turned,  but  no  further  suction 
made.  In  an  instant,  the  air  contained  in  the  tube  is  heard  ascending  through  the 
stop-cock  and  mounting  into  the  top  of  the  evacuator,  where  it  does  no  harm,  and 
whence  it  cannot  possibly  return  into  the  bladder. 


766 


OPERATIONS    ON    THE    ABDOMEN'. 


dilated,  leading  up  to  kidney  pelves  enlarged,  and  remember  that  the 
effects  of  any  squeeze  of  liis  hands  are  felt,  not  only  all  over  the 
bladder,  but  perhaps  in  the  ureters  and  kidneys  as  well. 

Detection  and  Seizure  of  Last  Fragment.— This  is,  as  is  well 
known,  a  matter  of  much  diiliculty,  owing  to  the  facility  with  which 

Fig.  126.* 


The  operator  is  here  supposed  to  be  sitting  between  the  tliighs  of  the  patient.  The  expansion 
of  the  compressed  bulb  will  aspirate  a  part  of  the  abundant  dfebris  suspended  in  the  fluid.  The 
fragments,  being  too  abundant,  have  been  dispersed.    (Bigelow.) 

small  fragments  get  hidden  in  some  folds  of  mucous  membrane  or 
enveloped  in  blood-clot.  As  long  as  there  is  any  "  clicking  "  against 
the  tube,  the  surgeon  must  persevere  in  his  attempts  at  complete 
removal.  If,  after  several  washings,  nothing  comes  out  into  the 
receiver,  the  surgeon  should  listen  carefully  over  the  bladder,  as  thus 
advised  by  Dr.  Keyes  :t  "  The  tube  is  turned  in  various  positions, 
and  the  operator  listens.  The  swash  of  the  water  as  it  rushes  in  and 
out  is  heard  with  startling  distinctness,  and,  if  the  management  of  the 


*  The  above  evacuator  is  now  old  fashioned.  Mr.  Golding  Bird's  pattern,  or  Mr, 
B.  Hill's  modification  of  Clover's,  will  be  found  the  most  handy. 

t  Loc.  supra  dt.,  p.  246.  The  whole  of  this  account,  with  its  vigorous  life-like  lan- 
guage, will  well  repay  perusal. 


LITHOTRITY — LITHOLAPAXY.  767 

tube  is  skilful,  any  fragment  of  stone  lying  loose  in  the  bladder  is  sure 
in  a  short  time  to  be  driven  against  the  metallic  tube  so  as  to  announce 
its  presence  by  a  characteristic  click,  quite  distinct  from  that  emitted 
by  the  flapping  of  the  bladder  wall  against  the  eye  of  the  instrument. 
Fine  sand  and  thin  scales  of  stone  make  no  sharp  click,  and  all  such 
may  be  left  to  pass  by  nature's  efforts,  but  any  piece  large  enough  to 
require  the  lithotrite  can  hardly  escape  detection  by  the  educated 
ear." 

Time  occupied  in  Litholapaxy. — This  may  be,  on  an  average,  from  half 
an  hour  to  an  hour  and  a  half.  Prof.  Bigelow  (Amer.  Journ.  Med.  Sci., 
January,  1878)  operated  continuously  for  upwards  of  three  hours, 
removing  744  grains,  the  patient  making  a  good  recovery.  Mr.  R. 
Harrison  {Brit.  Med.  Journ.,  August  10,  1882)  removed  a  2'/  oz.  stone 
in  two  hours  and  ten  minutes.  Sir  H;  Thompson  {Syst  of  Surg.,  vol. 
iii.  p.  298)  says  that  it  is  rarely  needful  to  prolong  an  operation  beyond 
fifty  or  seventy  minutes. 

The  Old  and  the  New  Operation  of  Lithotrity  briefly 
contrasted. — Old  lithotrity  advocated  short  sittings,  brief  use  of  in- 
struments, and  left  the  expulsion  of  fragments,  etc.,  as  much  as  pos- 
sible to  nature.  It  probably  requires  less  skill,  and,  in  Mr.  Cadge's 
words,  "is  gentler,  milder,  less  formidable  altogether;  no  aniKsthetic 

is  i^robably  required  ;   no  extra  assistance A  nervous,  timid 

patient  may  prefer  this  to  the  more  heroic  and  rougher,  if  more  ex- 
peditious, method."  It  might  be  added  that  it  is  less  tiring  to  the 
surgeon.  But  these  advantages  are  trifling  as  compared  with  its 
disadvantages,  which  are  done  away  with  b}^  the  new  operation,  of 
which  the  chief  are  the  prolonged  j^assage  of  fragments,  often  rough 
and  angular,  along  a  bruised  urethra. 

The  new  method  of  litholapaxy,  introduced  by  Prof.  Bigelow, 
resulted  from,  and  was  led  up  to  by,  several  achievements  of  modern 
surgery.  Without  anaesthetics,  without  the  knowledge  of  the  large 
instruments  admitted  by  the  urethra,  without  the  pitch  of  perfection 
and  power  to  which  modern  instruments  have  been  brought,  lithola- 
paxy would  still  be  an  impossibility.  Owing  to  its  brilliant  success, 
the  rapidity  with  which  it  relieves  the  patient,  the  single-sitting  method 
has  practically  rendered  the  other  obsolete. 

After-treatment. — The  chief  points  here  are :  rest  in  bed,  the 
patient  turning  on  his  side  to  pass  water,  for  the  first  four  or  seven 
days;  hot  fomentations  to  the  abdomen,  and  hot  bottles  at  first; 
morphia  subcutaneously,  if  indicated ;  warm  milk,  barley-water,  min- 
eral waters  or  lemonade,  a  little  whiskey  or  brandy  being  given,  if 
needful ;  all  chills  should  be  carefully  avoided. 

In  addition  to  the  above,  the  putting  the  patient  frequently  in  hot 
hip-baths  for  a  quarter  of  an  hour,  the  occasional  passage  of  a  soft 


768  OPERATIONS    ON    THE    ABDOMEN. 

catheter,  and  the  rendering  the  urine  alkaline  will  give  much  relief. 
The  urine  should  always  be  strained  through  muslin  to  collect  the 
debris. 
Complications  during  Lithotrity  and  Litholapaxy. 

1.  Escape  of  Urine. — This  may  take  |)lace  during  or  after  the  pass- 
age of  the  lithotrite.  The  penis  should  be  compressed  against  the 
lithotrite,  and  a  pause  made  while  the  patient  is  got  more  fully  under 
the  anaesthetic.  If  this  fail,  tying  a  tape  round  the  penis  and  instru- 
ment, injecting  a  little  fluid,  or  putting  off  the  operation  till  the 
bladder  is  in  a  more  fitting  state  after  the  use  of  instruments,  injec- 
tions, and  such  drugs  as  belladonna  and  subcutaneous  injections  of 
morphia,  may  be  made  use  of. 

2.  Haemorrhage. — Sufficient  blood  to  stain  the  fluid  in  the  evacuator 
during  the  operation,  and  the  urine  for  a  day  or  two  after  it,  is  not 
uncommon.  If  the  haemorrhage  during  the  operation  is  severe,  the 
surgeon  must  decide  whether  it  is  due  to  damage  to  the  bladder  or 
urethra,  to  his  having  scratched  the  latter  by  withdrawing  a  fragment 
in  the  evacuator's  eye,  to  bruising  of  an  enlarged  prostate,  or  to  coex- 
istent growth.  In  this  last  case  the  supra-pubic  operation  will  prob- 
ably have  to  be  performed  either  at  the  time  or  later ;  in  the  other 
cases  the  surgeon  must  decide  on  completing  or  deferring  the  crushing 
by  the  amount  he  has  already  effected,  his  experience,  and  the  amount 
of  the  bruising  inflicted. 

3.  Clogging  or  Fracture  of  the  Lithotrite. — Clogging  or  impaction  is 
liable  to  happen  Avith  a  non-fenestrated  instrument  with  Aveak  and 
narrow  blades.  With  one  properly  made,  with  as  broad  blades  as 
possible,  and  the  male  one  blunt,  roughened,  and  laterally  bevelled 
off,  the  accident  is  unlikely.  When  it  occurs,  it  must  be  met  by  per- 
cussing the  instrument,  if  opening  and  closing  the  blades,  and  thus 
freeing  them  in  the  fluid,  is  impossible.  If  the  impaction  persist,  the 
blades  must  be  withdrawn  as  far  as  possible  by  safely  maintained 
traction.  If  no  force  that  is  wise  will  withdraw  them,  they  should  be 
cut  upon  in  the  perineum,  thrust  out,  unloaded,  and  withdrawn,  and 
the  rest  of  the  stone  removed  as  by  a  median  lithotomy.  If,  owing  to 
any  defect  in  the  instrument,  the  blades,  though  not  clogged,  cannot 
be  screwed  up,  they  must  be  cut  upon  as  above,  thrust  through,  and, 
if  possible,  filed  off.  If  a  blade  break  off,  it  must  either  be  caught 
and  withdrawn  by  another  lithotrite,  or  the  patient  cut  at  once. 

4.  Injury  to  the  Bladder  or  Urethra. 

Complications  after  Litholapaxy  and  Lithotrity.— These 
are  much  the  same  as  those  already  given  at  p.  757  as  occurring  after 
lithotomy.*     The  chief  differences  are  the  greater  liability  to  rigors 

*  The  sSrae  want  of  space  that  caused  me  to  treat  these,  above,  too  briefly,  prevents 
my  going  into  them  again  here. 


LITHOLAPAXV    IX    MALE    CHILDREN.  769 

and  urinary  fever,  and  the  greater  frequency  of  epididymitis.  Bruis- 
ing of  the  urethra  has  also  to  be  remembered,  whether  by  the  instru- 
ments or,  after  the  old-fashioned  lithotrit}^  by  the  passage  of  fragments. 

LITHOLAPAXY  IN  MALE  CHILDREN. 

The  advisability  of  this  mode  of  treating  stone  is  still  sub  ju dice.  It 
has  been  strongly  advocated  by  Surgeon-Major  Keegan,*  who,  after  a 
wide  experience  of  large  stones  in  India,  is  inclined  to  think  that  the 
objections  usually  made  to  litholapaxy  in  boys  are  not  valid.  Thus — 
(1)  as  to  the  smallne--is  of  the  bladder,  the  bladder  of  a  boy  of  even  only 
three  or  four  is,  as  a  rule,  quite  roomy  enough  to  permit  of  the 
efficient  working  of  a  small  lithotrite  and  a  medium  or  full-sized 
aspirator  if  gently  worked.  The  bladders  of  boys  with  stone  are,  as  a 
rule,  healthy,  and  will  stand  more  distension  projDortionately  to  their 
capacity  than  the  bladders  of  old  men.  (2)  The  extreme  sensitiveness  of 
the  mucous  membrane  of  the  bladder  and  urethra.  Dr.  Keegan  thinks 
that,  with  an  an^psthetic,  this  may  be  safely  disregarded.  (3)  The 
liability  to  laceration  of  the  mucous  membrane  of  the  bladder  and  urethra. 
This  objection  is,  he  thinks,  a  theoretical  one  only.  (4)  The  smcdl 
calibre  of  the  urethra.  Dr.  Keegan  states  that  not  only  is  the  calibre  of 
the  urethra  in  boys  of  six  or  eight  not  very  small,  bu-t  that  of  boys  of 
only  three  or  four  is  sometimes  very  large.  As  in  men,  the  true  calibre 
of  the  urethra  cannot  be  told  unless  the  meatus,  which  is  sometimes 
very  small,  is  incised.  Speaking  generally,  the  urethra  of  a  boy  from 
three  to  six  will  admit  a  No.  7  or  a  No.  8  lithotrite  (Eng,  scale),  and 
that  of  a  boy  of  eight  or  tenr  will  admit  a  No.  10,  a  No.  11,  and  even 
sometimes  a  No.  14.  "  With  a  No.  8  lithotrite  and  a  No,  8  evacuating 
catheter  it  is,  I  find,  quite  feasible  to  dispose  of  a  mulberry  calculus 
weighing  between  two  and  three  hundred  grains  in  an  hour's  time.";}: 

Dr.  Keegan  insists  upon  the  completely  fenestrated  lithotrite  as  being 
the  only  perfectly  safe  instrument  to  use,  as,  with  any  other,  clogging 
of  the  blades  is  a  very  likel}"  and  a  most  dangerous  complication. 

"With  regard  to  the  two  principal  reasons  for  which  Dr.  Keegan 
advocates  litholapaxy  in  male  children,  rapidity  of  cure  and  absence 

*  Litholapaxy  in  Male  Children  and  Male  Adults  (Churchill,  1887) ;  Lancet,  1886. 

t  Mr.  W;ilshani  brought  before  the  Clinical  Society  {IVana.,  vol.  xix.  p.  240)  a  case 
of  litliotrjty  at  a  single  sitting  in  a  boy  aged  ten.  The  stone  here  was  very  small, 
weighing  15  grains,  and  lateral  lithotomy  had  been  performed  about  six  months  before. 

X  Dr.  Keegan  has  had  constructed  by  Messrs.  Weiss  a  lithotrite,  No.  6  in  the  stem 
and  in  the  angle,  which  will  readily  pass  through  the  urethrse  of  the  great  majority  of 
boys  of  between  two  and  three,  and  is  perfectly  capable  of  disposing  of  stones  weighing 
up  to  2  drachms.  A  rather  larger  one  is  No.  6  in  the  stem  and  No.  8  in  the  angle. 
Dr.  Keegan  advises  any  one  wishing  to  give  litholapaxy  in  boys  a  fair  trial,  to  provide 
himself  with  a  set  of  completely  fenestrated  lithotrites  running  from  No.  6  to  No.  10 
(Eng.  scale). 

49 


770  OPERATIONS  ON  THE  ABDOMEN. 

of  a  cutting  operation,  I  think  that  the  first  of  these  advantages  is  rather 
specious  than  real.  In  the  thirteen  cases  in  which  I  have  performed 
lateral  lithotomy  in  children  I  have  not  seen  any  of  "  the  suffering, 
annoyance,  and  personal  inconvenience  "  of  which  Dr.  Keegan  speaks 
as  following  this  operation.  I  may  be  wrong  as  well  as  old-fashioned 
in  this  matter,  but  I  think  that  a  child's  urinary  apparatus  just  freed 
from  a  stone  would  be  all  the  better  for  two  or  even  three  weeks'  rest- 
The  absence  of  a  cutting  operation  has,  no  doubt,  much  to  recom- 
mend it  in  a  country  like  India,  where  the  surgeon's  knife  has  greater 
terrors  with  parents  than  witli  us. 

It  is  with  the  utmost  unwillingness  that  I  seem  to  say  anything 
depreciating  Dr.  Keegan's  experience  and  authority,*  but  it  seems  to 
me  that  one  point,  the  most  important  of  all,  has  been  left  undealt 
with  by  him,  and  that  is  the  percentage  of  recurrence  in  children.  I 
have  already  (p.  761)  drawn  attention  to  the  frequency  of  this  in 
adults,  even  in  hands  so  especially  skilled  as  those  of  Sir  H.  Thompson 
and  Mr.  Cadge.  It  must  be,  no  doubt,  enormously  difficult  to  follow 
up  cases  in  India,  but  till  this  is  done  the  chapter  of  litholapnxy  in 
male  children  must  be  considered  very  incomplete.  I  must  conclude 
this  notice  of  the  subject  with  two  remarks.  One  is  that  it  must  not 
be  forgotten  that  these  fifty-eightf  cases  of  litholapaxy  in  male  chil- 
dren were  performed  on  Indian  patients ;  the  other,  that  such  an 
individual  experience  can  scarcely  be  thought  to  furnish  a  rule  to 
those  who  only  meet  with  stone  at  com})aratively  rare  intervals.  For 
these  reasons^  especially,  I  doubt  if,  in  Great  Britain,  lithotomy  in 
male  children  will  be  replaced  by  litholapaxy. 

TREATMENT    OF   STONE    IN    THE  BLADDER  IN  THE 

FEMALE. 

Practical  Points. — The  absence  of  any  prostate  or  of  a  fixed 
smooth  trigone  surface  is  of  importance  here,  especially  with  regard 
to  lithotrity.  The  aid  given  by  a  finger  in  the  vagina,  the  dilatability 
of  the  urethra,  the  association  of  calculi  with  foreign  bodies,  are  also 
well  known.  It  is  only  occasionally  that  enlargement  of  the  uterus 
or  prolapse  of  the  vaginal  wall  of  the  bladder  interferes  with  the 
treatment  of  stone. 

Operations. 

A.  Ill  Adults. — We  have  here  the  following  four  methods  to 
consider : 

1.  Dilatatioa. — When  the  stone  is  small — i.e.,  the  size  of  a  filbert. 


*  No  one  who  saw  the  series  of  crusiied  calculi  which  Dr.  Keegan  showed  at  the 
Association  meeting  at  Brighton  in  August,  1887,  could  have  helped  envying  him  his 
opportunities,  and  admiring  the  skill  with  which  he  had  made  use  of  them. 

t  Of  these,  only  two  ended  fatally;  in  neither  was  the  resiilt  due  to  the  operation. 


STOXE    IX    THE    BLADDER    IX    THE    FEMALE.  7^1 

a  stone  not  exceeding  I  inch  in  its  largest  diameter — it  may  be  safely 
removed  by  rapid  dilatation  with  Weiss's  instrument  guarded  with 
fine  drainage-tube,*  followed  by  a  finger  (the  little  one  first). 

2.  Litholapaxy. — By  this  means  calculus  in  the  female  bladder 
may  be  most  frequently  and  efficientl}^  treated.  Thus,  hard  stones 
under  an  ounce,  and  phosphatic  ones  of  a  much  larger  size,  may  be 
dealt  with  at  one  sitting.  The  character  of  the  ring  or  sound  with 
the  Staff,  the  bite  of  the  lithotrite,  and  the  condition  of  the  urine  will 
aid  bere.  A  shorter  instrument  will  be  found  much  more  convenient 
to  work  with.  Where  there  is  much  irritability  of  the  bladder  much 
difficulty  will  be  met  with  in  keeping  fluid  in  it,  owing  to  the  ab- 
sence of  a  i^rostate  and  the  shortness  and  directness  of  the  uretbra. 
The  jDelvis  must  be  well  elevated,  the  patient  placed  fully  under  the 
antesthetic,  and  the  finger  of  an  assistant  should  make  pressure  on  the 
urethra.  In  other  respects  the  operation  resembles  that  already  fully 
given  for  the  male  (p.  762).  The  dilatable  urethra  admits  a  full-size 
evacuating  tube. 

3.  Lithotomy. — This  operation  is  called  for  but  rarely — e.g.,  when 
the  stones  are  multiple,!  when  one  is  too  large,  especially  if  mainly 
hard  as  well,  when  there  is  a  foreign  body  as  a  nucleus,^  when  there 
is  great  irritability  with  ulceration  of  the  bladder,  or  when  a  growth 
co-exists. 

*  S(i  as  to  avoid  the  risk  of  splitting  the  soft  parts.  It  is  not  meant  bv  the  above 
remarks  that  much  hirger  stones  liave  not  been  successfully  passed  and  removed  from 
the  female  bladder.  Thus,  Dr.  Yelloly  (Med.  Chir.  Trans.,  vol.  vi.  p.  574)  gives  a 
case  in  whic!)  a  stone,  weighing  3  ozs.  SJ  drs.,  was  extracted:  incontinence  followed. 
Where  large  calculi — e.g.,  of  6  oz. — have  come  away  spontaneously,  it  has  been  usually 
by  a  process  of  prolapsus  and  ulceration  combined.  We  do  not  yet  know  what  is  the 
greatest  dilatation  which  the  female  urethra  will  safely  bear.  Perhaps  the  limitgiven 
above  is,  if  anything,  too  small.  Erichsen  {Surgery,  vol.  ii.  p.  1024)  gives  "8  or  10 
lines  in  diameter"  as  the  size  of  a  stone  which  can  be  safely  extracted  by  this  means. 
Sir.  H.  Thompson  (Syst.  of  Surg.,  vol.  iii.  p.  308)  says  "  dilatation  should  never  be 
employed  for  any  calculus  larger  than  a  small  nut  or  a  large  bean  in  an  adidt,  which 
limits  its  application  to  very  few  cases."  Mr.  Bryant  {Surgery,  vol.  ii.  p.  120)  states 
that,  "in  children,  a  stone  |  inch  in  diameter,  and  in  adults  1  i.ich,  mav  be  fearlessly 
removed  from  the  bladder  by  rapid  dilatation  and  extraction,  with  the  patient  under 
the  infl.ience  of  chloroform.  I  have  removed  larger  calculi,  2  inches  in  diameter,  by 
this  means,  without  any  injurious  after-effect,  but  it  is  probably  not  wise  to  make  the 
attempt,  the  surgeon  jmssessing  in  lithotrity  an  efficient  aid  or  substitute."  Dr.  Keves 
{Intern.  Encycl.  of  Surg.,  vol.  vi.  p.  297)  recommends  not  dilating  the  urethra  more 
than  f  incli. 

f  As  in  Dr  Galabin's  ca^^e  (Obd.  Soc  Trans.,  April  7,  1880),  in  which  twelve  large 
ealctdi  and  about  fifty  smaller  ones  were  removed  successfully  by  vaginal  lithotomy 
from  the  bladder  of  a  woman  aged  sixty-one. 

X  As  in  the  large  stone  formed  round  a  hair-pin,  and  figured  (p.  579)  bv  Hart  and 
Barbour  in  their  Manual  of  Gyncecology.  Here  the  projection  of  the  hair-pin  on 
either  side  of  the  stone  would  indicate,  nowadays,  the  supra-pubic  operation. 


772  OPERATIONS    OX    THE    ABDOMEN. 

Of  the  following  methods — (a)  vaginal,  (b)  supra-puhic,  (c)  urethral, 
and  (d)  the  lateral  method  of  Buchanan — the  first  two  only  need  be 
alluded  to. 

Vdf/innl  Lithotomy. — This  method  will  be  but  briefly  described  here, 
as  it  is  i)robable  that  for  stones  requiring  it — ?'.f.,  those  above  enumer- 
ated— tlie  supra-pubic  operation  is  better  suited.  The  risk  of  a  vesico- 
vaginal fistula,  always  present  in  the  operation,  is  especially  to  be 
remembered  in  cases  where  phosphatic  urine  is  present — a  condition 
frequently  met  with  in  the  case  of  large  stones  in  women,  or  where 
the  edges  of  the  wound  are  bruised  during  extraction.  The  greater 
readiness  with  which  a  catheter  is  passed  and  the  bladder  drained 
will  probably  make  the  modern  supra-pubic  operation  safe  in  women. 

By  vaginal  lithotomy  is  meant  extraction  of  a  stone  through  an 
incision  in  the  anterior  vaginal  wall,  behind  the  vesical  orifice  of  the 
urethra,  and  thus  not  interfering  with  this  canal  at  all. 

This  anterior  wall  is  about  4  inches  long  in  the  adult ;  in  relation 
with  it  is  anteriorly  the  urethra,  to  be  felt  as  a  cord  through  this  wall, 
behind  this  the  bladder,  and  farther  back  the  os  and  cervix  uteri. 
No  peritoneum  is  normally  in  relation  with  this  wall,  as  this  mem- 
brane leaves  the  uterus  half-way  down  to  pass  directly  on  to  the 
bladder.     No  important  vessels  or  nerves  are  met  with. 

Operation. — The  patient  being  in  litbotomy  position  and  the  vagina 
well  oi)ened  by  a  duck-bill  speculum  held  backwards  and  downwards 
against  the  posterior  vaginal  wall,  the  surgeon  introduces  a  short 
grooved  staff,  and,  having  made  the  groove  project  so  as  to  be  felt 
through  the  bladder  and  vagina,  cuts  straight  down  vxi^m  it  witli  a 
sharp-pointed  straight  bistoury,  making  an  incision  in  the  middle 
line  from  ?  to  2  inches  long  between  the  os  uteri  and  the  urethra, 
taking  care  not  to  cut  into  this  or  the  neck  of  the  bladder.  He  then 
introduces  his  finger  and  hooks  out  the  stone  with  this  or  with  scoop 
or  forceps. 

Another  and  a  simpler*  method,  if  the  stone  is  easily  caught,  is  to 
seize  it  with  small  forceps  passed  by  the  urethra,  and  so  to  hold  it 
that  it  projects  through  the  vaginal  wall,  and  to  cut  upon  the  stone 
itself  instead  of  upon  a  staff.f 

If  the  wound  remains  a  clean-cut  one,  unbruised  during  the  extrac- 
tion of  the  stone,  if  the  urine  is  sweet,  the  edges  should  be  closed  at 
once  with  silver  wire,  or  better  with  well-soaked  salmon-gut,  and  the 
case  treated  as  one  of  vesico-vaginal  fistula.     Under  less  favorable 


*  T.  Smith  and  Walsliam,  Man.  Oper.  Sury.,  p.  109. 

f  Dr.  Keyef  Hoc-  supra  cit.,  [>.  299),  advises  free  irrigation  of  the  bhidder  from  the 
uretlira,  the  vaginal  wall  being  held  open  till  all  fragments,  clots,  etc.,  have  been 
removed. 


STONE    IN   THE    BLADDER    IN    THE    FEMALE.  773 

conditions  closing  the  wound  may  have  to  be  deferred  till  the  parts 
are  quite  healthy. 

Supra-pubic  Lithotomy. — This  has  been  fully  described  at  p.  750. 
The  fluid  is  retained  in  the  bladder  by  finger-pressure  upon  the  orifice 
of  the  urethra. 

B.  In  Children. — I  cannot  do  better  than  quote  here  the  following 
conclusions  which  Mr.  Walsham  has  drawn  in  a  very  helpful  paper.* 

"  1.  That  for  small  stones,  both  rapid  and  slow  dilatation  of  the 
urethra,  in  children  as  in  adults,  are  good  operations.  2.  That  of  these 
two  rapid  dilatation  under  chloroform  is  perhaps  the  better,  as  caus- 
ing less  annoyance  and  inconvenience  to  the  patient.  3.  That  mod- 
erate- and  even  large-sized  stones  have  been  removed  by  dilatation, 
but  that,  as  incontinence  has  frequently  followed  from  over-distension, 
it  is  not  justifiable  to  subject  the  patient  to  this  risk.  4.  That,  after 
limited  dilatation,  should  the  stone  appear  larger  than  was  antici- 
pated, it  may  be  crushed  with  safety,  but,  should  crushing  be  con- 
sidered unadvisable  or  impossible,  it  is  better  to  perform  vaginal 
lithotomy  than  subject  the  j^atient  to  any  risk  of  incontinence  by  over- 
dilatation.  5.  That  it  is  not  safe  to  aid  the  dilatation  by  incising  the 
urethral  walls.  6.  That  incision  of  the  urethra  alone,  without  dilata- 
tion, in  whatever  direction  practiced,  is  frequently  attended  with 
incontinence,  and  should  therefore  be  abandoned.  7.  That  mod- 
erate and  even  large  stones  can  be  easily  removed  from  young 
children  by  vaginal  lithotomy,  aided,  if  necessary,  by  dilatation 
of  the  vagina,  incision  of  the  fourchette,  and  crushing  of  the 
stone  by  the  wound  made'  through  the  septum,  without  any  risk 
of  a  permanent  vesico  vaginal  fistula  so  long  as  the  edges  of  the  in- 
cision are  not  bruised  in  tne  extraction.  8.  That  the  incision  in  the 
septum  should  be  very  free,  but  not  involve  the  walls  of  the  urethra ; 
and  should  that  first  made  be  found  too  small,  it  should  be  enlarged 
before  any  attempts  at  extraction  are  undertaken.  9.  That  should  a 
fistula  remain  after  this  operation,  even  when  carefully  performed,  it 
can  be  readily  closed.  10.  That,  after  the  incision  has  been  prolonged 
to  the  limits  of  safety,  the  stone  still  appearing  too  large  for  easy  re- 
moval, and  crushing  being  considered  unadvisable  or  impracticable, 
it  is  better  to  open  the  bladder  above  the  pubes  than,  by  lacerating 
the  sides  of  the  wound  by  forcible  extraction,  to  subject  the  patient 
to  the  possible  danger  of  a  permanent  vesico-vaginal  fistula.  11, 
That  the  lateral  operation,  as  practiced  by  Dr.  Buchanan,  appears  well 
adapted  to  children  suffering  from  a  small  stone,  or  perhaps  one  of 
moderate  size  ;  and  that,  as  it  has  been  successfully  practiced  in  India 
and  Glasgow,  it  is  deserving  of  further  trial  in  this  country.     12.  That 

*  "  Stone  in  the  Bladder  of  Female  Children,"  St.  Barihol.  Hasp.  Beports,  vol.  xi. 
p.  129. 


774  OPERATIONS   ON   THE   ABDOMEN. 

very  largo  stones  can  only  be  removed  by  hypogastric  or  vaginal  lith- 
otomy ;  and  that  as  the  latter  proceeding  would  in  this  case  probably 
be  followed  by  a  permanent  vesico-vaginal  fistula,  it  is  better  to  choose 
the  more  dangerous  operation  than  subject  the  patient  to  this  loath- 
some affection.  13.  That  the  supra-pubic  operation,  when  carefully 
performed  is  possibly  much  safer  than  is  generally  supposed  ;  but 
that,  as  it  may  be  followed  by  death,  it  sliould  only  be  undertaken 
when  all  other  alternatives  threaten  permanent  incontinence." 

Mr.  Walsham  considers  each  of  the  above  separately  and  sui)ports 
them  with  evidence.  I  think  that  this  tends  to  show,  in  the  case  of 
vaginal  lithotomy,  that,  though  a  stone  may  be  extracted  in  this  way 
after  dilatation  of  the  vagina,  division  of  the  fourchete,  and  destruc- 
tion of  the  hymen,  it  is  by  no  means  easy  in  these  latter  cases  to 
insert  sutures  satisfactorily.  It  will  be  wiser,  I  think,  to  make  use  of 
the  supra-pubic  operation  in  female  children  for  all  save  the  very 
smallest  stones.  Lithotrity  is  by  no  means  easy  in  these  sm<dl  blad- 
ders, and  the  risk  of  vesico-vaginal  fistula  has  already  been  shown  to 
be  very  great. 

I  would  refer  my  readers  to  a  case  of  supra-pubic  operation  by 
Mr.  Barwell  in  a  child  aged  nine,  from  whom  a  stone  weighing  2t  ozs. 
was  successfully  removed.  It  is  interesting  to  note  that  Mr.  Barwell 
was  led  to  adopt  the  supra-pubic  operation  from  his  having  had 
within  seven  months  no  less  than  three  cases  of  vesico-vaginal  fistulse 
originating  in  the  extraction  of  calculi  during  infancy  and  youth  by 
different  surgeons  {_Med.  Chir.  Trans.,  vol.  Ixix.  p.  342). 

CYSTOTOMY. 

Indications. — The  operation  of  opening  the  bladder,  apart  from 
such  cases  as  exploring  for  growth,  foreign  body,  etc.,  may  be  re- 
quired in — 

1.  Some  cases  of  cystitis.  When  the  urine  is  fetid  and  slimy. 
When  pain  in  the  bladder  and  penis  is  intense,  leading  to  loss  of  sleep 
and  appetite.  When  there  is  a  high  temperature  and  other  evidence 
of  imminent  septicaemia.  When  all  other  treatment  has  failed,  and 
when  washing  out  is  insufficient  or  unendurable. 

The  operation  here,  for  the  sake  of  the  kidneys,  must  not  be  put  off 
too  late.  Much  benefit  may  be  obtained  by  irrigating  the  bladder 
freely,  and  afterwards  mopping  it  out  with  a  small  sponge  and  a  solu- 
tion of  silver  nitrate,  3ss  or  3j — .y. 

2.  Some  cases  of  great  irritability  of  the  bladder  persisting  after 
dilatation  of  a  stricture.  Mr.  R.  Harrison*  believes  that  the  continu- 
ance of  the  irritability  in  these  cases  is  due  to  the  muscular  hyper- 

*  Surg.  Dis.  of  the  Urin.  Org.,  p.  201. 


RUPTURED    BLADDER.  775 

troiDhy  which  the  bladder  has  undergone  in  its  constant  endeavors 
to  force  urine  through  the  obstruction  in  front  of  it,  and  that  the 
cystotomy  is  curative  by  bringing  about  atrophy  or  loss  of  that  mus- 
cularity. 

3.  Some  cases  of  tubercular  cystitis.  Here  the  bladder  may  be 
drained  to  give  relief  from  intense  suffering. 

4.  As  part  of  other  operations.  Thus,  in  plastic  operations  about 
the  urethra,  to  keep  the  parts  dry,  the  bladder  may  be  opened.  I 
have  done  this  in  a  case  of  epispadias. 

5.  As  this  operation  will  not  again  be  alluded  to,  I  may  remind  my 
readers  that  cystotomy,  or,  rather,  opening  the  prostatic  urethra  on  a 
staff,  has  been  recommended  by  Sir  H.  Thompson  in  those  few  but 
most  distressing  cases  of  enlarged  prostate  leading  to  hourly  cathe- 
terism,  cystitis,  loss  of  sleep,  and  other  aggravated  symptoms.* 

The  above  are  instances  of  cases  calling  for  cystotomy.  The  sur- 
geon will  have  to  choose  between  three  operations — viz.,  median  and 
lateral  cystotomy  and  external  urethrotomy.  The  median  operation 
is  almost  always  to  be  preferred  to  the  lateral,  but  it  is  probable  that 
external  urethrotomy  (pp.  737,  783)  will  be  sufficient  as  to  drainage, 
and  it  is  certain  that  this  operation  is  less  risky  from  shock,  cellulitis, 
and  secondary  h^znorrhage.  The  great  object  is  to  drain  the  cavity 
thoroughly. 

Supra-pubic  cystotomy  is  employed  occasionally  in  Hunter's 
method  of  treating  stricture  by  passing  a  sound  from  the  bladder  up 
to  the  perineum. 

RUPTURED  BLADDER 

The  treatment  of  this  hitherto  most  fatal  injury  has  of  late  years 
been  cleared  up.f  Exploratory  operations  and  suture  of  the  bladder 
will  be  increasingly  successful  in  favorable  cases — i.e.,  those  seen  early 
and  those  in  which  the  injury  is  limited  to  the  bladder. 

Two  forms  of  rupt.'.re  are  recognized — the  intra-  and  extra-peritoneal. 
It  may  be  well  to  state  succinctly  the  symptoms, 

latra-peritonefd  Rupture. — (1.)  History  of  a  likely  injury.  (2,)  In- 
ability to  pass  water.J;  This  power  has,  however,  been  preserved  in 
both  varieties ;  naturally  it  is  seen  most  frequently  and  in  greater 
perfection  in  extra-jjeritoneal  cases.  It  is  very  rarely  normal  in  the 
intra-peritoneal  ruptures.     (3.)  A  little  bloody  urine  drawn  off  with  a 

*  D is.  of  tke  Prostate,   p.  176. 

t  Especially  by  Sir  W.  MacCormae's  paper,  with  two  successful  cases,  Luncei,  18S0, 
vol.  ii.  p.  118. 

X  Thus  the  rent  may  be  valvular  or  blocked  by  intestine,  etc.  On  all  these  ami 
many  other  points  the  reader  sliould  refer  to  Mr.  Kivington's  writings  (Diet,  of  Surg., 
vol.  i.  p.  152)  and  Rupture  of  the  Urinary  Bladder,  for  e.\haustive  completeness  and 
helpful  information. 


776  OPERATIONS   OX    THE    ABDOMEN. 

catheter.  (4.)  Difficulty  of  manipulating  an  instrument  in  a  con- 
tracted bladder.  (5.)  If  the  catheter,  hitting  off  the  rent,  be  passed 
beyond  the  bladder,  a  much  larger  quantity  of  blood-stained  fluid  is 
withdrawn,  partly  urine,  partly  serum,  from  irritation  of  the  peri- 
toneum,* (6.)  Speedy  (usually)  supervention  of  peritonitis.  (7;) 
Perhaps  fluctuation  and  dulness  in  the  flanks. 

Eitra-peritoneal  Rupture. — (1.)  History  of  a  likely  injury.  (2.)  In- 
ability to  pass  water  (vide  supra) .  (3.)  A  little  bloody  urine  drawn  off. 
(4.)  The  catheter  finds  the  bladder  contracted.  (5.)  No  tapping  of  a 
larger  amount  of  fluid.  (6.)  Evidence  of  extravasationf  rather  than 
of  peritonitis. 

It  must  be  remembered  that  the  following  may  mislead  :  There  may 
be  very  little  pain  complained  of;  no  sickness ;  a  normal  temperature  5 
the.  patient  may  be  able  to  walk  ;  upwards  of  half  a  pint  of  urine  may 
be  drawn  off  night  and  morning,  and  yet  the  peritoneal  cavity  may 
contain  much  fluid.  Peritonitis  may  be  absent  post-mortem,  though 
tympanites  be  present  during  life,  and  though  fluid  be  found  in  the 
peritoneal  cavity.  The  patient  may  live  five  days,  apparently  im- 
proving,, and  then  die  suddenly. 

Operation. — The  patient  being  under  an  antesthetic,  the  abdomi- 
nal wall  cleansed  and  shaved  and  the  parts  relaxed,']:  a  free  incision, 
5  or  6  inches  long  in  the  adult,  is  made  in  the  middle  line.  The  linea 
alba  being  divided,  the  recti  retracted  and  partly  detached  if  needful,  all 
bleeding-points  secured,  the  lower  angle  of  the  wound  and  the  parts 
behind  the  pubes  are  carefully  examined  for  ecchymosis,  extravasation, 
etc.  If  neither  of  these  nor  any  collection  of  fluid  is  found  outside  the 
peritoneum,  this  is  opened,  when  a  large  gush  of  fluid  may  be  decisive. 
The  surgeon  now  introduces  one  finger  to  feel  the  rent,  and  the  detec- 
tion of  this  may  be  facilitated  by  passing  a  short-beaked  sound.  The 
rent  will  vary  in  site  and  length, §  and  also  as- tO' regularity,  thickening, 
etc.  If  it  be  a  long  oae,  and  reach  downwards  towards  the  recto- 
vesical cul-de-sac,  the  introduction  of  a  rectal  bag  (Figs.  123,  124,  pp. 
751,  752)  may  be  of  assistance.  Sir  W.  MacCormac  also  found  that 
the  bladder  came  up  more  readily  after  the  parietal  peritoneum  had 

*  If  the  flow  ihrongli  the  catheter  is  niiirkedly  increased  by  inspiration  and  dimin- 
ished by  expiration,  the  rent  is.  probably  a  large  one. 

f  Thus,,  if  the  rent  is  in  front,  the  urine  may  be  locaJiaed  tliere  with  circumscribed 
diiilness ;  or  widely  diffused,,  mounting  up  towards  the  umbilicus,  between  the  at)d(>m- 
inal  muscles  and  the  peritoneum  ;  or  passing  into  the  iliac  fossse,  or  by  the  canals  into 
the  scrotum  and  thighs. 

X  In  Mr.  Willett's  case  {St.  Burthd.  Hasp.  Reports,  vol.  xii.  p.  209)  nuich  difficulty 
was  met  with  from  the  rigidity  of  tlie  abdominal  walls,  and  the  great  distension  of  the 
intestines,  which  kept  crowding  out  of  the  wonnd^  and  were  :»m>sS  difficult  to  replace. 
Peritonitis  had  set  in  here,  tweiity-fonr  hours  having  elapsed  since  the  injury. 

\  In  Sir  W.  MacCoxmajc's  cases  the  Esnts  were  4  and  2  inches  long. 


RUPTURED    BLADDER.  777 

been  transversely  divided  on  each  side.  An  assistant  with  carefully 
cleansed  hands  may  render  service  at  this  time  by  hooking  up  the 
bladder  with  two  fingers,  while  the  intestines  are  kept  back  with 
sponges.  The  rent,  being  now  in  view,  is  cleansed,  and  sutures  of 
fine  carbolized  silk  inserted.  Sir  W.  MacCormac  used  sixteen  of  these 
in  one  case  and  twelve  in  another,  and  his  success  is  largely  due  to  the 
great  care  with  which  they  were  inserted.  Thus,  they  are  put  in  i 
inch  apart,  after  Lembert's  method  (Fig.  107,  p.  665),  including  the 
serous  and  muscular  coats  only,  beginning  at  the  lower  part,  and  the 
first  and  last  sutures  being  inserted  well  beyond  the  limits  of  the 
injury  so  as  to  prevent  leakage  from  the  extremities.  Tlie  following 
precautions  are  taken  in  passing  them:  Fine  curved  needles  are  used 
on  holders ;  the  serous  surfaces  are  carefully  inverted.  The  sutures 
are  passed  through  the  serous  and  muscular  coats  only.  This  avoids 
the  risk  of  traversing  the  mucous  membrane,  which  in  animals  has 
nearly  always  proved  fatal,  because — (1)  on  tightening  the  sutures, 
the  mucous  membrane  falls  between  the  edges  of  the  wound  and 
hinders  union;  (2)  the  urine  may  find  a  channel  through  the  points 
of  passage  of  a  suture,  and  so  into  the  cavity  of  the  peritoneum  ;  (3) 
the  loop  of  suture  within  the  bladder  is  a  foreign  body,  and  salts  may 
be  deposited  on  it. 

Wherever  a  gap  appears,  another  suture  should  be  inserted.  If  there 
is  time,  a  few  of  chromic  gut  may  be  inserted  through  the  serous  coat 
only,*  but  Sir  W.  MacCormac  regards  the  double  row  as  unnecessary  ; 
8  or  10  oz.  of  boracic  acid  are  then  injected  into  the  bladder,  to  see  if 
it  is  water-tight ;  or  a  colored  fluid,  such  as  Condy's  lotion,  may  be 
used.  A  few  more  sutures  may  be  required  till  this  fact  is  absolutely 
certain.  The  peritoneal  cavity  is  now  most  carefully  sponged  out  with 
sponges  on  ovariotomy  clamp-forceps,  pushed  well  down  into  the 
pelvis  and  the  flanks  till  they  come  out  clean  and  dry  on  squeezing. 
Sir  W.  MacCormac  made  use  of  another  method  of  cleansing  the  peri- 
toneum which  proved  simple  and  efficient — viz.,  irrigating  the  perito- 
neal cavity  with  2  gallons  of  a  1  per  cent,  solution  of  boracic  acid 
dissolved  in  boiled  Avater,  and  used  at  a  temperature  of  98°.  The 
tubing  to  which  the  nozzle  or  catheter  is  attached  should  have  a 
stop-cock,  that  the  flow  may  be  regulated.  All  the  fluid  should  be 
got  out  again  by  turning  the  patient  over,  holding  the  edges  of  the 
wound  apart,  etc. 

In  one  of  Sir  W.  MacCormac's  cases  a  drainage-tube  was  passed 
from  the  centre  of  the  wound  into  the  recto-vesical  cul-de-sac.  In 
one  case  a  catheter  was  tied  in;  in  the  other  (the  slighter  case),  in 

*  Sutures  throiiffli  the  serous  coat,  only,  invariably  tciye  way. 


778  OPERATIONS  ON  THE  ABDOMEN. 

which  no  catheter  was  left  in,  urine  was  passed  involuntarily  a  few 
hours  after  the  operation  ;  this  went  on  at  short  intervals  till  the  third 
day,  when  the  control  became  complete. 

PUNCTURE  OF  THE  BLADDER. 

The  followinii'  methods  will  be  considered  here: 
i.  The  Aspirator. 
ii.  Supra-pubic  Puncture. 
iii.  Puncture  per  Rectum. 
iv.  Puncture  through  the  Prostate. 

i.  The  Aspirator. — This  may  be  used  in  cases  of  great  urgency, 
when  the  surgeon  is  compelled  to  relieve  retention  without  regard  to 
the  cause;  when  he  is  without  the  means  of  carrying  out  other  and 
perhaps  better  methods ;  it  is  especially  suited  to  those  cases  in  which 
there  is  reason  to  believe  that  urine  will  again,  in  a  few  hours,  be 
passed  by  the  urethra.  Thus,  in  gonorrhoea!  retention  where  a  catheter 
cannot  be  passed,  having  perhaps  been  clumsily  used,  and  where  relief 
is  urgently  required,  where  retention  has  supervened  on  a  stricture  of 
only  two  or  three  years'  standing  it  may  be  used  successfully,  giving 
time  for  warm  baths  and  opium  to  act.  In  an  old  stricture,  in  one  of 
traumatic  origin,  or  in  a  case  of  enlarged  prostate,  it  can  only  be  a 
temporary  measure,  and  should  only  be  used  when  other  instruments 
are  not  available. 

The  question  arises,  How  far  will  aspiration  bear  repetition  f  This  is 
quite  uncertain.  On  the  one  hand,  in  a  case  of  prostatic  retention  not 
admitting  a  catheter,  the  patient  being  throughout  in  a  most  grave 
condition,  Dr.  Brown  (Brit.  Med.  Journ.,  May  23,  1874)  used  the  aspi 
rator  fifteen  times  between  January  2d  and  12th,  "  with  immediate 
relief  on  every  occasion,  and  without  the  smallest  inconvenience  or 
injury  from  the  punctures."  Mr.  Hague  (Lancet,  1885,  vol.  ii.  p.  385), 
in  a  patient,  aged  ninety,  wnth  prostatic  retention  of  forty-eight  hours' 
duration,  aspirated,  and  continued  to  do  so  daily  for  nearl}^  five  weeks, 
as  no  catheter  could  be  passed.  Such  numerous  aspirations  caused  no 
ill  effects. 

On  the  other  hand,  in  a  case  of  mine  of  prostatic  retention  in  which 
the  aspirator  had  been  used  only  three  times,  on  the  death  of  the 
patient  from  bronchitis  on  the  fourth  day,  the  third  and  last  puncture 
was  found  to  be  leaking.  Dr.  Campbell  (Brit.  Med.  Journ.,  February 
21,  1886)  records  a  case  in  which  the  bladder  had  been  aspirated 
twice,  internal  urethrotomy  was  performed,  "progress  was  good  for  a 
day  or  two,  when  some  inflammation  appeared  at  one  of  the  punctures, 
an  abscess  formed,  peritonitis  came  on,  and  the  man  died."     Where 


PUN'CTURE    OF    THE    BLADDER.  779 

aspiration  is  to  be  used,  the  condition  of  the  bladder  walls  and  of  the 
urine  must  be  taken  into  account* 

If  aspiration  be  made  use  of,  a  fine  needle  should  be  employed,  and 
introduced  just  above  the  pubes  while  an  assistant  steadies  the  blad- 
der by  pressure  on  either  side.  The  bladder  must  not  be  allowed  to 
become  much  distended  before  the  puncture  is  repeated,  otherwise 
urine  may  be  forced  out. 

ii.  Supra-pubic  Puncture. — Tliis  operation  has  the  advantages 
of  being  easily  performed,  of  giving  permanent  relief  if  desired,  and 
of  being  safe. 

The  two  objections  brought  against  it  are  that  (1)  it  gives  bad  drain- 
age and  (2)  it  is  liable  to  extravasation.f  Neither  of  these  is  borne 
out  by  facts.  While  the  patient  is  in  bed,  good  drainage  can  be  pro- 
vided by  turning  him  on  his  side  and  attaching  tubing  to  the  cannula ; 
when  the  patient  is  up  (and  a  cannula  so  placed  is  no  drawback  to 
this),  the  power  of  micturition  wall  probably  have  returned.  In  a  few 
cases  of  enlarged  prostate  the  patient  will  be  compelled  to  pass  his 
urine  this  way  for  the  rest  of  his  life,  but  as  soon  as  the  parts  are  consoli- 
dated around  the  cannula,  or  the  catheter  which  has  replaced  the  can- 
nula, micturition,  though  tedious,  will  be  effected  satisfactorily. 

I  may  allude  to  three  cases  in  which  I  have  used  this  method  in  the 
last  six  months — two  of  retention  with  stricture,  one  of  prostatic  reten- 
tion. I  consider  it  the  best  all-round  method,  and  the  one  of  widest 
application  that  we  have.  Its  relief  is  immediate,  safe,  and  simple 
wdthal.  The  two  cases  of  stricture  were  men  under  forty,  admitted 
with  a  history  of  catheterism,  bleeding  urethra?,  and  recent  false 
passages.  On  the  fifth  day,  with  the  aid  of  ether,  I  was  able  to  get  a 
No.  7  silver  catheter  into  the  bladder.  For  some  cases  of  older 
strictures,  especially  if  with  fistulae  and  damaged  perineum,  a  longer 
rest  is  required,  and  Mr.  Cock's  or  Mr.  Wheelhouse's  operation  are 
indicated. 

Operation. — This  is  most  simple.  A  median  puncture  being  made 
through  the  skin  just  above  the  shaved  pubes,  I  prefer  a  curved  trocar 
and  cannula,:|:  the  latter  carrying  tape-holes,  but  a  straight  trocar  and 

*  Mr.  Bennett  read  a  case  before  the  Medico-Chirnrgical  Society  {Lancet,  vol.  i. 
1888,  {)  418)  of  extra-peritoneal  rupture  of  the  bladder  after  aspiration  in  a  patient  long 
the  subject  of  stricture.  The  opinion  of  most  surgeons  present  seemed  to  be  that  aspi- 
ration was  dangerously  liable  to  leakage,  especially  in  unhealthy  bladders. 

t  Mr.  T.  Smith  (St.  Barthol.  Hosp.  Reports,  vol.  xvii.  p.  291  writes:  "  I  have  seen 
no  such  tendency  to  extravasation;  occasionally  there  is  some  inconvenience  from 
leakage;  this  may  be  met  by  leaving  out  the  cannula  for  a  few  hours,  which  allows 
recontraction  to  take  place." 

X  A  very  useful  form  is  made  by  Arnold.  The  cannula  appears  too  long,  but  is  not 
so  for  very  fat  abdominal  walls.  It  is  easily  retained  in  place  by  tapes,  and  the  urine 
runs  oft"  by  tubing.     To  keep  the  cannula  firm  at  first,  I  insert  a  silver  suture  in  the 


780  OPEHATIONS  ON  THE  ABDOMEN. 

cannula  may  be  used,  through  which  an  8  or  9  gum-elastic  catheter 
or,  better,  a  Jaques's  catheter  is  inserted  ;  in  four  hours  the  cannuhi 
can  be  removed,  and  a  larger  catheter,  a  10  or  12,  introduced  * 

iii.  Puncture  per  Rectum — This  has  the  advantage  of  draining 
a  bladder  well,  but  there  are  such  serious  disadvantages  connected 
with  it  that  the  supra-pubic  operation  is  always  to  be  preferred  to  it. 

Thus  (1),  it  is  difficult  and  most  unpleasant  to  the  patient  to  retain 
the  cannula  during  defecation  and  passage  of  flatus — the  retention  of 
a  cannula  is  liable  to  cause  troublesome  tenesmus  and  diarrhoea  ;  (2) 
Avhen  the  cannula  slips  out  it  is  difficult  to  replace  it;t  (3)  the  patient 
is  kept  in  bed  ;  (4)  this  method  is  not  applicable  to  cases  of  enlarged 
prostate.  I  am  aware  that  Mr.  Bryant  (Surgery,  vol.  ii.  p.  153)  states 
that  "  an  enlarged  prostate  is  no  real  obstacle  to  its  performance,  for 
this,  if  necessary,  may  be  perforated  with  impunity."  I  cannot  at  all 
agree  with  the  above,  in  spite  of  Mr.  Bryant's  authority.  Being  one 
of  those  who  look  upon  an  enlarged  prostate,  especially  when  congested 
with  retention  and  surrounded  by  an  enlarged  venous  plexus,  as  a 
structure  to  be  treated  with  great  respect,  I  think  that  there  is  an 
undoubted  risk  that  perforating  it  may  lead  to  septic  phlebitis  and 
abscess,  and  to  suppuration  in  already  impaired  kidneys. 

Mr.  Bryant  ( loc.  supra  cit.)  speaks  very  highly  of  puncture  per  rectum, 
and  says  that  the  objections  raised  against  it  are  theoretical  only — 
viz.,  abscess  between  the  bladder  and  rectum,  persistent  fistulous 
opening,  injury  to  the  vesicular  seminales  or  the  peritoneum.  I  do 
not  deny  that  these  injuries  are  rare,  but,  as  compared  with  supra- 
pubic puncture,  the  drawbacks  wliich  I  have  given  above  are  practical 
and  undoubted. 

Operation. — If  this  method  is  employed,  Mr.  Cock's  instruments 
should  be  made  use  of — viz.,  a  very  sharp  and  a  blunt  pilot  trocar,  and 
a  cannula  with  inner  tubes  to  kee})  the  cannula  in  position  and  to 
admit  of  its  being  cleansed.  The  patient  being  in  lithotomy  position 
and  the  rectum  emptied,  the  surgeon  feels  for  the  distended  bladder, 
behind  the  prostate,  with  his  left  index  finger.  This  being  kept  in  situ, 
he  introduces  the  cannula  and  blunt  pilot  along  the  finger  up  to  the 
point  he  intends  to  puncture.     The  pilot  being  withdrawn,  the  sharp 

puncture,  cover  this  with  iodoform  and  collodion,  and  pack  some  strips  of  dry  ganze 
aronnd.  I  generally  give  a  little  anaesthetic,  but  this  is  not  needed.  The  skin  punct- 
ure is  alone  painful. 

*  If  an  aspirator  has  been  used,  and  it  is  desired  to  replace  it  with  a  catheter,  a 
catgut  bougie  should  be  passed  through  the  cannula,  and,  this  being  withdrawn,  a  small 
gum-elastic  catheter,  with  an  eye  in  its  point,  is  passed  over  the  bougie.  Larger  ones 
can  soon  be  got  in,  passing  them  with  terminal  eyes  over  the  smaller  ones,  or  by  means 
of  a  stylet  (T.Smith). 

t  Thus,  there  are  two  specimens  in  Guy's  Hospital  Museum  proving,  by  the  double 
puncture  present,  that  this  is  the  case. 


RUPTURED    URETHRA.  781 

trocar  is  introduced,  and,  when  it  is  nearly  up  to  the  hilt  in  the  can- 
nula, it  is  depressed  and  then  driven  on  in  a  direction  upwards  and 
forwards,  as  if  aiming  for  the  umbilicus.  The  trocar  is  then  withdrawn, 
the  inner  tubes  inserted,  and  the  whole  secured  with  tapes.  The  urine 
is  best  conveyed  away  by  tubing. 

iv.  Puncture  through  the  Prostate.— Mr.  R.  Harrison  *  has 
advocated  this  method,  and  published  a  most  successful  case  in  a 
patient,  aged  eighty-four,  with  prostatic  retention.  A  special  straight 
trocar  was  introduced  in  the  middle  line  I  inch  in  front  of  the  anus, 
and  pushed  steadily  through  the  prostate  into  the  bladder,  the  left 
index  being  retained  in  the  rectum.  The  cannula  was  removed  in 
nearly  three  months,  natural  micturition  gradually  returning.  Atro- 
ph}'  of  the  enlarged  prostate  appeared  to  follow,  and  the  symptoms 
were  much  relieved. 

I  cannot  but  think  that  this  method  runs  the  risk  of  septic  phlebitis 
{vide  supra).  Another  objection  is  that  the  patient  is  kept  in  bed. 
Micturition  becomes  natural  much  more  quickly  after  supra-pubic 
puncture. 


CHAPTER  XIII. 

OPERATIONS    ON    THE     URETHRA    AND     PENIS. 

RUPTURED  URETHRA. -EXTERNAL  URETHROTOMY. 
—CHOICE  OF  OPERATION  FOR  RELIEF  OF  STRIC- 
TURE-RETENTION. —  INTERNAL  URETHROTOMY. 
—EPISPADIAS.-HYPOSPADIAS.— CIRCUMCISION  — 
AMPUTATION  OF  PENIS. 

RUPTURED  URETHRA. 

In  a  small  number  of  cases  the  surgeon  may  succeed  in  passing  a 
catheter  into  the  bladder.  If  he  do  so  in  a  case  where  there  has  been 
much  bruising  t  of  the  peritoneum  and  extravasation  of  blood,  a  median 
incision  should  still  be  made  to  allow  of  relief  to  tension  and  escape 
of  clots  as  they  break  down,  and  so  to  give  good  drainage.  If  this  is 
not  done,  the  probability  is  great  that  a  little  later,  owing  to  damage 
of  soft  parts,  tension  of  blood-clot,  and  a  little  escape  of  urine  by  the 
side  of  the  catheter,  this  step  will  be  required,  at  a  time  when,  from 
the  presence  of  ti'aumatic  fever,  and  the  condition  of  the  extravasated 
blood,  the  occasion  is  less  favorable.     Again,  though  a  catheter  can  be 

*  Intern.  Eneyd.  of  Surg.,  vol.  vi.  p.  414. 

f  Complete  rupture  of  the  urethra  may  coexist  with  a  mere  contusion  of  the  peri- 
neum, especially  if  much  tenderness  is  present. 


782  OPERATIOXS   ox   THE   ABDOMEN. 

passed  at  the  time,  it  by  no  means  follows  that  when,  owing  to  its 
being  plugged,  or  from  some  other  reason,  it  requires  removal  in  a  few 
days  that  a  fresh  one  can  be  inserted.  An  incision  will  then  have  to 
be  made,  and,  as  already  stated,  under  conditions  less  favorable. 

When,  as  is  usually  the  case,  a  catheter  cannot  be  passed  into  the 
bladder,  the  patient  is  placed  in  lithotomy  position,  and  the  parts 
being  shaved  and  cleansed,  a  grooved  staff  of  as  full  size  as  the  parts 
will  admit  is  passed  as  far  as  it  will  go — i.e.,  to  the  site  of  the  rupture, 
it  is  then  made  to  project  in  the  perineum,  and  the  surgeon  entering  a 
straight  sharp-pointed  bistoury  in  the  middle  line  at  a  point  1  inch  to 
I2  inch  above  the  anus,  pushes  it  on  till  it  strikes  the  groove,  and  then 
cuts  along  this,  both  upwards  and  downwards,  so  as  to  expose  freely 
the  spot  at  Avhich  the  urethra  is  ruptured.  As  the  knife  is  brought  out 
the  skin  woimd  is  enlarged  till  this  is  about  I2  inch  long,  the  lower 
end  being  2  inch  above  the  anus. 

With  the  finger  clots  are  now  turned  out,  and  retractors  being 
inserted  deeply,  the  wound  is  sponged  out  thoroughly.  A  good  deal 
of  bleeding  may  now  take  place  from  some  wounded  vessel,  hitherto 
closed  by  extravasated  blood,  or  from  the  crus  penis,  detached  on  one 
side  by  the  violence  which  ruptured  the  urethra,  especiall3Mf  there  be 
a  fractured  pelvis.  This  hsemorrhage  will  yield  to  firm  pressure  or  to 
forcipressure.  The  anterior  end  of  the  urethra  is  next  readily  found 
by  the  end  of  the  staff,*  which  projects  through  it,  the  finding  of  the 
deeper  or  vesical  end,  often  difliicult,  will  be  facilitated  by  careful 
sponging,  a  mirror,  and  reflected  light,  pressure  above  the  pubes,  and 
the  use  of  fine  probes  or  straight  gum-elastic  catheters.  This  end  often 
projects  as  a  small  clot  or  bleeding-point,  at  other  times  it  resembles 
a  partly  twisted  artery. 

If  it  be  ibund,  a  catheter  of  as  large  size  as  possible  should  always 
be  introduced,  if  practicable,  from  the  meatus,  and  then  through  the 
vesical  end  of  the  urethra  into  the  bladder,  guided  by  a  finger  in  the 
wound,  a  Brodie's  probe,  or  a  Teale's  gorget  (Fig.  129).  If  this  be 
found  impracticable,  a  catheter  should  be  passed  into  the  bladder  from 
the  wound.  One  of  these  methods  should  always  be  made  use  of,  if 
possible,  as  it  enables  the  patient  to  be  kept  dry  by  tubing  attached 
to  the  catheter. 

But  if  no  catheter  can  be  got  into  the-ljladder,  either  along  the  penis 
or  from  the  wound,  the  surgeon  need  not  worry  himself  as  long  as  a 
free  exit  has  been  given  for  the  urine  and  extravasated  blood.  In 
these  cases  it  is  not  unusual  for  the  bladder  to  become  somewhat  dis- 
tended  during  the  first  two  or  three  days,  owing  to  the  urine  not 


*  The  farther  back  tlie  tear,  the  greater,  of  course,  the  difBculty  in   finding   the 
urethra. 


EXTERNAL   URETHROTOMY  783 

escaping  with  sufficient  freedom,  or  to  the  closure  of  the  vesical  end 
of  the  urethra  from  swelling  after  the  injury  and  the  manipulations 
to  find  it,  or  from  the  patient,  if  a  cliild,  shrinking  from  passing  his 
water.  This  difficulty  will  usually  be  met  by  hot  flannels  frequently 
applied  to  the  abdomen,  a  few  doses  of  laudanum,  but  if  it  be  evident 
that  the  urine  does  not  escape  with  sufficient  freedom,  the  surgeon 
must  again  examine  the  wound  with  the  aid  of  an  aniesthetic,  clean 
out  any  fresh  clots,  and  again  try  to  find  the  vesical  end  of  the  urethra, 
aided  now  perhaps  by  a  better  light. 

If  this  fail,  supra-pubic  tapping  or  aspiration,  or,  if  the  patient's 
condition  be  good,  making  a  small  supra-pubic  opening  into  the 
bladder  and  thence  passing  a  short  curved  staff  into  the  perineum 
and  so  finding  the  vesical  end  of  the  urethra,  must  be  resorted  to. 

Urethritis  and  cystitis  are  not  uncommon  in  children.  They  are 
best  met  by,  as  soon  as  possible,  leaving  out  the  catheter  for  a  while. 

With  regard  to  the  advisability  of  trying  to  use  sutures,  it  is  always 
advisable,  if  possible,  to  draw  the  ends  of  the  urethra  together  on  the 
catheter,  with  a  fine  curved  needle  on  a  holder,  and  chromic  gut  or 
carbolized  silk.  But  this  will  be  often  found  a  matter,  of  great  diffi- 
culty, and  even  impossible.  When  effected,  it  does  not  diminish  the 
need  of  subsequent  regular  use  of  catheters. 

EXTERNAL  URETHROTOMY. 

This  operation  includes  the  different  forms  of  perineal  section  with 
or  without  a  guide — viz.,  Syme's,  Wheelhouse's  and  Cock's  operation. 

By  some,  external  urethrotoray  is  reserved  for  those  cases  such 
as  Syme's,  in  which  a  staff  can  be  passed  through  the  stricture,  and 
*'  perineal  section"  tor  those  in  which  no  such  help  is  available — 
e.g.,  Mr.  Cock's  operation.  As,  however,  these  terms  are  readily  con- 
fused b,y  students,  and  as  in  Wheelhouse's  operation  a  staff  is  used, 
though  it  cannot  be  passed  through  the  stricture,  I  think  it  preferable 
to  employ  the  term  external  urethrotomy,  specifying  which  operation 
is  meant  by  using  the  author's  name — viz.,  Syme's  external  urethro- 
tomy, etc. 

Syme's  External  Urethrotomy.— Here  the  stricture  is  divided 

on  a  fine  staff  (vide  infra)  passed  through  it. 

Indications. — This  excellent  operation  is  strongly  indicated  in  (1) 
cases  of  stricture  which  do  "  not  yield  to  dilatation,  or,  rather,  con- 
tinue to  present  symptoms  after  being  dilated  " — in  other  words,  to 
contractile,  irritable,  and  resilient  strictures,  in  which  dilatation  is 
accompanied  with  much  pain,  or  in  which  it  is  found  that  a  No.  7  can 
perhaps  be  passed  one  day  and  only  a  No.  8  a  da}'^  or  two  after ;  (2) 
cases  in  which  rigors  and  constitutional  disturbance  follow  any  attempt 
at  dilatation. 

Operation. — The  patient,  being  prepared  by  mild  aperients  and 


784  OPERATIONS  ON  THE  ABDOMEN. 

bland  liquid  diet  for  the  operation,  is  brought  under  an  anaesthetic, 
and  while  the  legs  hang  over  the  end  of  the  table,  the  surgeon  intro- 
duces a  Syme's  staff.  This  has  a  narrow  terminal  portion,  which 
passes  through  the  stricture,  a  shoulder  which  rests  upon  the  face  of 
the  stricture,  and  a  wider,  stouter  part  above  the  shoulder  to  make 
the  instrument  easier  to  find  in  the  perineum.  The  patient  being 
placed,  in  a  good  light,  in  lithotomy  position,  and  the  parts  cleansed 
and  shaved,  the  surgeon  makes  an  incision  exactly  in  the  median 
line  down  upon  the  staff,  exposing  the  wider  portion  above  the 
shoulder.  When  the  surgeon  is  certain  that  this  is  laid  bare,  he  runs 
the  knife  forwards  along  the  groove,  so  as  to  divide  the  stricture  com- 
pletely. The  staff  is  now  withdrawn,  and  the  rest  of  the  treatment 
must  vary  somewhat.  If  the  condition  of  the  patient  admits  of  it,  a 
full-sized  gum-elastic  catheter  should  be  passed  from  the  meatus  into 
the  bladder,  guided  by  a  finger  in  the  wound  or  in  the  rectum,  or  by 
a  grooved  director  passed  from  the  perineum.  If  the  irritability  of 
the  parts  does  not  admit  of  this,  a  gum-elastic  catheter  must  be 
inserted  from  the  perineum,  cut  short,  and  kept  in  situ  with  tapes, 
the  urine  running  off,  by  tubing  attached,  into  a  basin  containing 
carbolic  acid ;  or  Prof.  Syme's  curved  perineal  catheter  may  be 
employed. 

As  soon  as  a  catheter  can  be  passed  from  the  meatus,  it  should  be 
kept  in  for  two  or  three  days,  and  changed,  if  needful,  Avith  an  anaes- 
thetic at  first.  As  soon  as  possible,  it  should  be  passed  twice  a  day, 
and  the  patient  should  be  clearly  told  of  the  absolute  necessity  which 
exists  of  keeping  up  the  good  effects  of  the  operation  by  passage  of  an 
instrument  at  regular  intervals,  and  of  occasionall}^  re2:>orting  himself 
to  his  surgeon. 

Wheelhouse's  External  Urethrotomy.— Here  the  stricture 

is  first  found  by  a  staff  passed  down  to  it,  and  then  divided  on  a  fine 
probe-pointed  director  passed  through  it. 

Mr.  Wheelhouse  (Brit.  Med.  Jouni.,  June  24,  1876)  recommends  his 
method  as  having  "  the  advantage  of  greatly  increased  precision ;  it 
renders  an  operation,  confessedly  hitherto  one  of  the  most  difficult 
in  surgery,  a  comj^aratively  easy  one,  and  one  which,  in  my  hands 
and  those  of  my  colleagues,  has  given  results  infinitely  more  favorable, 
with  an  immediate  and  ultimate  effect  upon  our  cases,  than  we  had 
ever  seen  before  its  introduction." 

Operation. — "  Tlie  patient  is  placed  in  lithotomy  position,  with 
the  pelvis  a  little  elevated,  so  as  to  permit  the  light  to  fall  well  upon 
it,  and  into  the  wound  to  be  made.     The  staff*  (Fig.   127)  is  to  be 

*  This  is  fully  grooved  througli  the  greater  part,  but  not  throiigli  the  whole  of  its 
extent,  the  last  half  inch  of  the  groove  being  '"stopped"  and  terminating  in  a  round 
button-like  end. 


WHEELHOUSE  S    EXTEEXAL   URETHROTOMY. 


'85 


introduced  with  the  groove  looking  toward  the  surface  and  brought 
gently  into  contact  with  the  stricture.  It  should  not  be  pressed  much 
against  the  stricture,  for  fear  of  tearing  the  tissues  of  the  urethra  and 
causing  it  to  leave  the  canal,  which  would  mar  the  whole  after-pro- 
ceedings, which  depend  upon  the  urethra  being  opened  a  quarter  of  an 
inch  in  front  of  the  stricture.  Whilst  an  assistant  holds  the  staff  in  this 
position,  an  incision  is  made  into  the  perineum,  extending  from  oppo- 


FiG.  127. 


Fig.  128. 


(Wheelhouse.) 


(Wheelhouse.) 

site  the  point  of  reflection  of  the  su})erficial  fascia  to  the  outer  edge  of 
the  sphincter  ani.  The  tissues  of  the  perineum  are  to  be  steadily 
divided  until  the  urethra  is  reached.  This  is  now  to  be  opened,  in 
the  groove  of  the  staff,  not  upon  its  iwint,  so  as  certainly  to  secure  1  inch 
of  healthy  tube  immediately  in  front  of  the  stricture.  As  soon  as  the 
urethra  is  opened,  and  the  groove  in  the  staff  fully  exposed,  the  edges 
of  the  healthy  urethra  are  to  be  seized  on  each  side  with  straight- 
bladed  nibbed  forceps  and  held  apart.  The  staff  is  then  to  be  gently 
withdrawn  until  the  button-point  appears  in  the  wound.  It  is  then 
to  be  turned  round,  so  that  the  groove  may  look  to  the  pubes  and  the 
button  may  be  hooked  on  to  the  upper  angle  of  the  opened  urethra, 
Avhich  is  then  held  stretched  open  at  three  points  thus  (Fig.  128),  and 
the  operator  looks  into  it  immediately  in  front  of  the  stricture.    While 

50 


786 


OPERATIONS  ON  THE  ABDOMEN. 


thus  held  open,  a  probe-pointed  director*  is  inserted  into  the  urethra, 
and  the  operator,  if  he  cannot  see  the  opening  of  the  stricture,  which 
is  often  possible,  generally  succeeds  in  very  quickly  finding  it,  and 
passes  the  point  outwards  throuf/h  the  stricture  towards  the  bladder. 
The  stricture  is  sometimes  hidden  amongst  a  crop  of  granulations  or 
warty  growths,  in  the  midst  of  which  the  probe-point  easily  finds  the 
true  passage.  The  director  having  been  passed  into  the  bladder  (its 
entrance  into  Avhich  is  clearly  demonstrated  by  the  freedom  of  its 
movements),  its  groove  is  turned  downwards,  the  whole  length  of  the 
stricture  is  carefully  and  deliberately  divided  on  its  under  surface,  and 


Fig    129. 


Fig.  130. 


(Whfelhouse.) 


(Teale.) 


the  passage  is  thus  cleared.  The  director  is  still  held  in  the  same 
position,  and  a  straight  probe-pointed  bistoury  is  run  along  the  groove 
to  ensure  complete  division  of  all  bands  or  other  ol)structions.  These 
being  thoroughly  cleared,  the  old  difficulty  of  directing  the  point  of  a 
catheter  through  the  divided  stricture  and  onwards  into  the  bladder 
is  to  be  overcome.  To  effect  this,  the  point  of  a  Teale's  probe-gorget 
(Fig.  129)  is  introduced  into  the  groove  in  the  director,  and,  guided 
by  it,  is  passed  onwards  into  the  bladder,  dilating  the  divided  stricture, 
and  forming  a  metallic  floor,  along  which  the  point  of  the  catheter 
cannot  fail  to  pass  securely  into  the  bladder.  The  entry  of  the  gorget 
into  the  latter  viscus  is  signalized  by  an  immediate  gush  of  urine  along 
it.  A  silver  catheter  (No.  10  or  11)  is  now  passed  from  the  meatus 
down  into  the  wound,  is  made  to  pass  once  or  twice  through  the 


*  Or  a  common  blunt-pointed  probe  may  be  used. 
3)  is  useful. 


Occasionally  a  bougie  (No.  2  or 


cock's  external  urethrotomy.  787 

divided  urethra,  where  it  can  be  seen  in  the  wound,  to  render  certain 
the  fact  that  no  obstructing  bands  have  been  left  undivided,  and  is 
then,  guided  by  the  probe-dihator,  passed  easily  and  certainly  along 
the  posterior  part  of  the  urethra  into  the  bladder  (Fig.  130).  The 
gorget  is  now  withdrawn,  the  catheter  fastened  in  the  urethra  and 
allowed  to  remain  for  three  or  four  days,  an  elastic  tube  conveying 
the  urine  away.  After  three  or  four  days  the  catheter  is  removed,  and 
is  then  passed  daily,  or  every  second  or  third  day,  according  to  circum- 
stances, until  the  wound  in  the  perineum  is  healed ;  and  after  the  parts 
have  become  consolidated,  it  requires,  of  course,  to  be  passed  still  from 
time  to  time  to  prevent  recontraction."* 

This  will  be  found  a  most  eifectual  operation,  but  I  have  found  the 
hitting  off  of  the  mouth  of  the  stricture  to  be  a  less  simple  matter  than 
Avould  be  gathered  from  Mr.  Wheelhouse's  account.  This  is  especially 
the  case  Avhen  the  parts  are  engorged  and  softened,  as  the  free  oozing 
which  is  met  with  under  these  conditions  may  be  most  diflicult  to 
arrest  even  Avith  firmly  applied  sponges  on  holders,  the  slightest 
trickling  of  blood  being  sufficient  to  obscure  the  orifice  of  the  stricture. 
A  false  passage  at  the  site  of  the  stricture  may  complicate  matters  very 
much,  and  a  stricture  in  the  penile  portion  of  the  urethra  may  prevent 
the  passage  of  the  staff  altogether.  A  good  light,  gentleness  and 
patience  are  at  all  times  requisite. 

Cock's  Operation. — An  external  urethrotomy,  which  opens  the 
urethra  behind  the  stricture,  and  without  a  guide  (Fig.  131).  The 
following,  in  the  words  of  its  deviser,  are  the  advantages  of  this  oper- 
ation so  well  known  to  Guy's  men  :t  "  The  bladder  is  reached  without 
any  unnecessary  mutilation  of  the  perineum.  The  communication  is 
effected  in  nearly  a  straight  line  from  the  exterior  to  the  cavity  of  the 
viscus,  so  that  the  cannula,  which  is  inserted  and  retained,  can  be 
removed  whenever  necessary,  and  can  be  easily  replaced.  The  func- 
tions of  tlie  entire  urethra  are  suspended,  and  may  be  kept  in  abey- 
ance for  an  unlimited  period.  The  urine  no  longer  finds  its  way 
abnormally  through  the  stricture  and  sinuses  of  the  perineum.  The 
tissues  are  no  longer  subjected  to  constant  irritation  from  infiltration. 
The  constitutional  symptoms  are  relieved,  and  time  and  opportunity 
are  given  for  the  ren)oval  by  absorption  of  those  adventitious  products 
Avhich  obstructed  the  urethra,  indurated  the  perineum,  and  rendered 
the  introduction  of  an  instrument  impossible.  The  pressure  on  the 
kidneys  is  removed,  and,  if  expedient,  the  bladder  may  be  readily 

*  The  wound  should  be  irrigated  occasionally  during  the  operation  with  a  solution 
of  boracic  acid,  or  Thouii  son's  fluid,  and  a  little  iodotbrni  dusted  in  at  the  close.  If 
any  bleeding  is  going  on,  the  wound  should  be  jilugged  around  the  catheter  with  strips 
of  iodoform  or  sal  alenibroth  gauze. 

f  Guy's  Hosp.  Reports,  186(3,  vol.  xii.  p.  267. 


788  OPERATIONS  ON  THE  ABDOMEN. 

washed  out,  until  its  lining  membrane  assumes  a  healthy  character. 
The  strictured  and  damaged  portion  of  the  urethra,  being  no  longer 
subjected  to  the  constant  pressure  of  urine  from  behind,  may  probably 
so  far  recover  itself  as  to  allow  of  restoration  by  the  ordinary  means 
of  dilatation  ;  or,  should  the  canal  have  become  permanently  oblit- 
erated, the  patient  still  retains  the  means  of  emptying  his  bladder 
through  the  artificial  opening  without  difficulty  or  distress,  and  at  very 
moderate  inconvenience  to  himself." 

The  following  are  the  cases  to  which  the  operation  is  well  suited  : 
Where  the  stricture  has  existed  for  a  number  of  years;  where  the 
urethra  has  become  permanently  obstructed  or  destroyed  by  the  con- 
stant pressure  of  urine  from  behind,  and  by  reiterated  attempts, 
generally  fruitless,  to  introduce  an  instrument;  where  extravasation 
into  the  perineum  has  again  and  again  taken  place,  causing  rej)eated 
abscesses  and  their  consequences,  the  formation  of  urinary  sinuses 
and  fistulse,  until  the  normal  textures  of  the  perineum  become  oblit- 
erated, and  are  replaced  by  an  indurated,  gristly  structure  ;  where  the 
bladder  has  become  thickened  and  contracted  by  the  constant  action 
of  its  muscular  coat  until  little  or  no  cavity  is  left,  and  where  the 
urine  is  constantly  distilling  b}^  drops,  either  through  the  urethra  or 
through  one  or  several  fistulous  openings,  which  dot  the  surface  of  the 
perineum,  penetrate  through  the  indurated  scrotum,  and  even  find 
their  way  to  the  nates  below,  and  the  region  of  the  pubes  above.  If 
unrelieved,  these  cases  invariably  terminate  fatally. 

The  keystone  of  the  whole  proceeding  is  the  fact  that,  ''  however 
complicated  may  be  the  derangement  of  the  perineum,  and  however 
extensive  the  obstruction  of  the  urethra,  one  portion  of  the  canal 
behind  the  stricture  is  always  healthy,  often  dilated,  and  accessible  to 
the  knife  of  the  surgeon.  I  mean  that  portion  of  the  urethra  which 
emerges  from  the  apex  of  the  prostate — a  part  which  is  never  the  sub- 
ject of  stricture,  and  whose  exact  anatomical  position  may  be  brought 
under  the  recognition  of  the  finger  of  the  operator." 

This  operation  has  the  following  advantages :  A  catheter  is  readily 
retained  and  replaced.  The  urine,  no  longer'finding  its  way  through 
sinuses,  the  indurated  tissues  are  absorbed.  Such  entire  rest  is  given 
to  the  damaged  urethra  that  it  usually  recovers  itself.  The  bladder 
is  easily  washed  out. 

Operation. — "  The  patient  is  to  be  placed  in  the  usual  position  for 
lithotomy ;  and  it  is  of  the  utmost  importance  that  the  body  and  pel- 
vis should  be  straight,  so  that  the  median  line  may  be  accurately 
preserved.  The  left  forefinger  of  the  operator  is  then  introduced  into 
the  rectum,  the  bearings  of  the  prostate  are  next  examined  and  ascer- 
tained, and  the  tip  of  the  finger  is  lodged  at  the  apex  of  the  gland. 
The  knife  is  then  plunged  steadily,  but  boldly,  into  the  median  line 


cock's  external  urethrotomy. 


789 


of  the  perineum,  and  carried  on  in  a  direction  towards  the  tip  of  the 
left  forpfinger,  which  Hes  in  the  rectum.  At  the  same  time,  by  an 
upward  and  downward  movement,  the  vertical  incision  may  be  carried 


Fig.  131. 


Mr.  Cock's  Operation.    (Bryant.) 

in  the  median  line  to  any  extent  that  is  considered  desirable.  The 
lower  extremity  of  the  wound  should  come  to  within  *  inch  of  the 
anus. 

"  The  knife  should  never  be  withdrawn  in  its  progress  towards  the 
apex  of  the  prostate,  but  its  onward  course  must  be  steadily  main- 
tained, until  its  point  can  be  felt  in  close  proximity  to  the  tip  of  the 
left  forefinger.  When  the  operator  has  fully  assured  himself  as  to  the 
relative  position  of  his  finger,  the  apex  of  the  prostate,  and  the  point 
of  his  knife,  the  latter  is  to  be  advanced  with  a  section  somewhat  ob- 
liquely, either  to  the  right  or  the  left,  and  it  can  hardly  fail  to  pierce 
the  urethra.  If,  in  this  step  of  the  operation,  the  anterior  extremity 
of  the  prostate  should  be  somewhat  incised,  it  is  a  matter  of  no  con- 
sequence. 

"In  this  operation  it  is  of  the  utmost  importance  that  the  knife  be 
not  removed  from  the  wound,  and  that  no  deviation  be  made  from  its 
original  direction  until  the  object  is  accomplished.  If  the  knife  be 
prematurely  removed,  it  will  probably,  when  reinserted,  make  a  fresh 
incision  and  complicate  the  desired  result.  It  will  be  seen  that  the 
wound,  when  completed,  represents  a  triangle ;  the  base  being  the 
external  vertical  incision  through  the  perineum,  while  the  apex,  and 
constantly  the  point  of  the  knife,  impinges  on  the  prostate.  This 
shape  of  the  wound  facilitates  the  next  step  of  the  operation. 

"  The  knife  is  now  withdrawn,  but  the  left  forefinger  is  still  retained 
in  the  rectum.  The  probe-pointed  director  is  carried  through  the 
wound,  and  guided  by  the  left  forefinger,  enters  the  urethra,  and  is 


790  OPEUATIONS    ON    THE    ABDOMEN. 

passed  into  the  bladder.  A  No.  12  gum-elastic  catheter,  straightened 
on  its  stylet,  is  slid  along  the  director,  the  stylet  then  removed,  the 
catheter  cut  short,  and  secured  in  position  with  tapes." 

While  most  fully  alive  to  the  excellence  of  this  operation,  both  as 
to  speediness  of  relief  and  the  perfect  rest  it  gives  to  damaged  parts, 
I  should  like  to  point  out  to  those  who  are  only  likely  to  perform  it 
occasionally,  (a)  that  it  is  not  such  an  easy  operation  as  it  appears; 
(b)  that  it  is  a  severer  operation  than  the  size  of  the  wound  would 
suggest.  Hiiemorrhage  is  not  very  uncommon  from  the  engorged  con- 
dition of  the  parts,  and  a  low  form  of  septic  phlebitis  is  not  very 
infrequent  after  the  operation.  For  these  reasons  I  would  restrict  it 
to  the  cases  mentioned  at  p.  788. 

Complications  and  Causes  of  Failure  after  External 
Urethrotomy. 

1.  Haemorrhage  (p.  787). 

2.  Rigors.  These  should  be  met  by  warmth,  leaving  out  the  cath- 
eter or  substituting  a  softer  one ;  plenty  of  diluent  drinks,  washing 
out  the  bladder  with  diluted  Thompson's  fluid  (p.  751).  Dover's 
powder,  or  injections  of  morphia,  if  the  condition  of  the  kidney  admits 
of  these.  Five  or  ten  grains  of  quinine  may  be  given  in  milk  every 
two  or  three  hours,  if  it  does  not  excite  vomiting. 

3.  Septic  troubles— e.gr.,  septic  phlebitis. 

4.  Pelvic  cellulitis. 

5.  Persistence  of  a  fistulous  opening  in  the  perineum. 

6.  Recurrence  of  the  contraction. 

CHOICE    OF  AN  OPERATION  FOR    THE    RELIEF    OF 
STRICTURE-RETENTION.* 

It  will  have  been  gathered  from  the  remarks  at  p,  778  that  supra- 
pubic aspirationf  maybe  used  in  very  urgent  cases,  and  may  be 
repeated  safely  once.  For  the  large  majority  of  cases  of  retention  due 
to  stricture,  especially  where  the  patient  is  under  forty- five,  and  a  few 
days'  rest  will  ensure  the  passage  of  a  catheter,  I  believe  that  supra- 
pubic tapping  of  the  bladder  will  be  the  safest  and  simplest  operation. 
This  will  be  followed  in  four  or  five  days  by  the  passage  of  a  catheter, 
aided  by  an  anaesthetic,  and  guided  by  a  little  judicious  force,  com- 
bined with  a  knowledge  of  anatomy.  Wheelhouse's  operation  is  very 
highly  spoken  of  by  the  Leeds  surgeons.  A  good  light  and  especial 
instruments  are  essential.^  The  cases  to  which  Mr.  Cock's  excellent 
operation  should  be  limited  have  been  already  pointed  out  (p.  788). 

*  The  su[)ra-]iiibic  tapping  has  been  already  recommended  for  retention  dne  to  an 
enhirged  prostate. 

t  In  the  absence  of  an  aspirator,  an  ordinary  hydrocele  trocar  may  l>e  safely  used. 
X  I  onght  to  say  that  I  have  only  used  this  operation  twice. 


INTERNAL    URETHROTOMY.  791 


INTERNAL  URETHROTOMY. 

Indications. — Before  specifying  these  I  would  say  that  with 
regard  to  the  question  between  external  and  internal  uretlirotom}-,  it 
is  chiefly  a  matter  of  personal  experience.  In  other  words,  surgeons 
who  practice  frequently  some  such  operation  as  that  of  Prof.  Syme, 
and  I  confess  I  am  of  the  number,  will  probably  have  as  good  results 
as  those  who  resort  to  internal  urethrotomy.  As  it  is  a  clean  division 
of  the  entire  stricture  which  is  required,  this  can  be  effected  most 
readily,  and  with  less  skill,  and  with  simpler  instruments,  by  external 
urethrotomy.  But  it  must  be  remembered  that  after  all  it  is  not  so 
much  the  division  of  the  stricture,  whether  from  without  or  within, 
which  will  be  curative,  as  the  amount  of  perseverance  which  the  pa- 
tient shows  afterwards.  Again,  at  the  commencement  of  internal 
urethrotomy,  each  stricture  must  be  dilated  sufficiently  to  admit,  in 
the  case  of  an  instrument  cutting  from  without  in  wards,  a  split  sound 
equivalent  to  No.  2  English,  while  in  instruments  cutting  in  the 
opposite  direction,  the  bulb  is  as  large  as  No.  4  or  5.  This  being  so, 
the  cases  must  be  very  few  in  which  the  surgeon  does  not  find  it 
possible,  and  in  which  the  patient  does  not  prefer,  to  complete  the 
case  b}'  dilatation. 

Amongst  these  few  cases  are — 

1.  Strictures  localized  and  of  the  nature  of  annular,  which  (a)  con- 
tract rapidly  after  dilatation,  or  (,5)  in.  which  rigors  persistently  follow 
attempts  at  dilatation. 

2.  Non-dilatable  strictures — e.g.,  some  traumatic  ones. 

3.  Penile  strictures.  As  these  are  very  elastic  and  shrink  quickly 
after  dilatation,  and  as  incision  of  these  strictures  seldom  causes 
serious  constitutional  disturbance. 

4.  In  some  cases  where  time  is  an  object.  Thus,  in  young  subjects 
whose  disease  has  not  existed  long  enough  to  alter  the  condition  of 
the  kidneys,  cutting  may  be  admissible  for  a  stricture  that  should  be 
simply  dilated  in  an  older  patient  whose  kidneys  have  undergone 
considerable  degeneration.* 

5.  According  to  some,t  urethrotomy  affords  a  longer  interval  of 
freedom  from  contraction  than  does  any  other  plan  of  widening  a 
stricture. 

Contra-indications, 

1.  Strictures  not  localized  and  ring-like,  but  extending  over  con- 
siderable surface. 


Berkeley  Hill,  Diet,  of  Surg.,  vol.  ii.  p.  727. 
Berkeley  Hill,  loc.  supra  cU. 


792  '  OPERATIONS   ON   THE   ABDOMEN. 

2.  A  "  stricture  "  in  which  the  difficulty  is  mainly  due  to  con- 
gestion *  though  this  is  scarcely  a  stricture  at  all. 

3.  A  stricture  accompanied  by  urethritis. 

I  have  endeavored  to  point  out  fairly  the  indications  for  internal 
urethrotomy.  I  suspect  that  this  is  one  of  those  operations  of  which 
an  increasingly  frequent  use  is  liable  to  lead  to  something  very  like 
abuse.  But  however  this  may  be  I  should  like  to  point  out  first  a 
fallacy  as  it  seems  to  me.  Thus  Sir  H.  Thompson  (Dis.  of  Urin. 
Organs,  p.  40)  speaks  of  a  urethrotome  as  "  nothing  more  than  a  little 
knife  with  a  long  blade  ....  used  preciselj'-  as  we  use  a  scalpel  any- 
where else.  Just  as  we  should  use  a  small  knife  in  tenotomy,  without 
the  sense  of  vision,  where  it  is  not  necessary,  but  guided  by  the  sense 
of  touch,  so  do  I  advise  you  to  act  in  urethrotomy."  No  doubt  this 
comparison  is  correct  as  far  as  it  goes,  but  its  very  simplicity  is 
misleading.  There  can  be  no  real  comparison,  I  maintain,  between 
division  of  a  tendon  which  can  always  be  practically  made  subcuta- 
neous, and  that  of  a  stricture,  perhaps  4  inches  from  the  surface, 
surrounded  by  vascular  tissue,  incision  of  which  may  easily  lead  to 
haemorrhage  or  septic  trouble,  an  incision  which  cannot  from  the 
subsequent  flow  of  urine  be  completed  aseptically,  and  which  impli- 
cates other  parts  in  such  intimate  sympathy  with  that  operated  on — 
e.g.,  the  kidneys. 

Again,  I  would  point  out  that  internal  urethrotomy  is  not  the  very 
simple  affair  that  it  is  sometimes  represented  to  be.  I  would  refer 
my  reader  to  the  experience  of  one  whose  name  is  associated  with  this 
operation.  Mr.  Berkeley  Hillf  speaks  thus  of  a  trial  which  he  gave 
to  the  method  of  treating  early  stricture  by  Otis's  operation  of  internal 
urethrotomy : 

•'  All  the  cases  operated  on  were  those  of  long-standing  gleets,  with 
contraction  in  one  or  more  parts  of  the  spongy  urethra,  and  had 
undergone  multifarious  treatment.  The  number  of  patients  is  sixteen, 
fifteen  of  my  own,  and  one  of  Dr.  Otis's.  In  five  cases  the  gleet  stopped 
after  the  operation  and  the  patient  was,  at  the  last  report — taken 
in  none  less  than  three  weeks,  in  most  some  months,  after  the  opera- 
tion— able  to  pass  a  bougie  of  the  estimated  size  of  the  urethra.  In 
short,  they  may  be  claimed  as  cures.  But  of  these  five  the  operation 
was  serious  to  two ;  one  had  free  bleeding  for  three  days,  the  other 
three  attacks  of  rigors.  Of  the  remaining  eleven,  among  whom  Dr, 
Otis's  own  operation  must  be  included,  the  gleet  persisted  in  all;  in 

*  As  bearing  upon  the  allied  condition  of  "spasm,"  the  above  surgeon  {Brit.  Med. 
Journ.,  1879,  vol.  ii.  p.  856)  states  that  if  an  apparently  narrow  biilbo-membranous  and 
a  penile  stricture  coexist,  on  the  latter  being  properly  divided,  the  former  will  dis- 
appear, having  been  due  to  reflex  muscular  contraction. 

t  Lancet,  April  8,  1876,  p.  524. 


INTERNAL    URETHROTOMY.  793 

several  the  urethra  shrank  again  to  its  size  before  the  operation,  and 
in  some  very  serious  complications  ensued.  In  four  bleeding  lasted 
several  days,  and  in  one  was  even  alarming.  Three  patients  had 
rigors ;  in  two  the  shivering  was  unimportant,  being  that  which 
follows  the  first  transit  of  urine  along  tlie  incised  urethra  in  certain 
individuals,  but  is  not  repeated  or  attended  by  further  consequences. 
In  the  third  patient  the  rigors  preceded  abscess  in  the  buttock.  One 
patient  had  orchitis.  Thus,  in  seven  the  operation  might  fairly  be 
termed  a  trifle,  causing  no  pain  nor  any  after-fever,  but  in  five  only 
was  the  operation  successful." 

Complications. — (1)  Haemorrhage.  If  severe  this  may  be  met 
by  pressure  on  the  perineum,  with  a  pad  or  a  stick  in  the  bed  so  that 
the  patient  may  keep  up  the  compression  himself.  (2)  Perineal  ab- 
scess, (o)  Sloughing  and  perineal  fistula.  These  are  very  rare.  (4) 
Extravasation.  (5)  Septicaemia.  (6)  Epididymitis.  The  first  five  of 
these  are  usually  due  to  cutting  too  deeply,  or  to  the  patient  not 
being  sufficiently  prepared  or  unfit  for  the  operation.  The  last  is 
usually  brought  about  by  injudicious  haste  in  the  use  of  bougies. 

The  essentials  of  a  good  urethrotome  are:  (1)  a  guide  through  the 
stricture  into  the  bladder,  usually  in  the  form  of  a  filiform  guide- 
bougie,  or  of  a  curved  terminal  portion  of  the  urethrotome,  sufficiently 
fine  to  pass  through  the  narrowest  stricture  ;  (2)  a  cutting  edge  which, 
at  first  shielded,  can  be  protruded  by  the  surgeon  as  exactly  and  as 
deeply  as  he  desires  ;  (3)  some  means  of  steadying  the  mobile  strict- 
ure fibres  as  they  are  divided. 

Two  Chief  Modes  of  Internal  Urethrotomy.— The  stricture 
may  l)e  divided— (//)  From  without  inwards— /.f.,  towards  the 
bladder.  ij>)  From  within  outwards,  away  from  the  bladder. 

A  short  account  of  the  chief  instruments  will  be  given,  and  the  two 
methods  briefly  contrasted. 

a.  Those  Cutting  from  Without  Inwards. — By  this  means 
narrower  strictures  can  be  divided  than  in  the  other  method,  in  Avhich 
the  instruments  used  are  usually  based  on  Civiale's  pattern,  in  which 
the  bulbous  end  carries  the  knife  (p.  795). 

Most  of  the  urethrotomes  which  cut  from  without  inwards  are 
modifications  of  a  Maisonneuve's  pattern.  A  fine  hollow  staff  being 
guided  through  the  stricture  by  a  filiform  bougie,  along  the  hollow 
staff"  a  stylet  carrying  a  triangular  shield  or  wedge  is  run  ;  this  pushed 
against  the  stricture  serves  to  stead}'  it,  while  it  is  divided  by  a  knife 
concealed  in  the  wedge  or  shield. 

One  of  the  best  known  of  the  recent  instruments  on  this  pattern  is 
Mr.  B.  Hill's.  It  consists  of  a  narrow  split  sound,  No.  2  English, 
which  can  be  guided  through  narrow  tortuous  strictures  by  being 


794  OPERATIOXS  ON  THE  ABDOMEN. 

attachecl  to  a  filiform  bougie,  previously  passed  into  the  bladder.* 
Secondly,  a  wedge  runs  along  dovetail  grooves  between  the  halves  of 
the  split  sound.  In  this  wedge  is  concealed  a  knife  that  can  be  pro- 
truded between  the  halves  of  the  split  sound,  when  the  stricture- 
tissue  prevents  their  separation  sufficiently  to  allow  the  wedge  to 
pass  on.  The  wedge,t  pushed  up  to  the  situation  of  the  stricture,  in 
separating  the  split  sound  tightens  and  steadies  the  stricture  thor- 
oughly, while  the  knife  divides  it  to  the  width  required  by  the  wedge 
to  pass  along.:|:  If  a  wedge  be  chosen  to  expand  the  urethra  to  its 
full  natural  capacity,  the  cut  will  not  pass  beyond  the  stricture  into 
the  vascular  erectile  tissue  external  to  it.  The  knife  can  be  applied 
to  the  upper  or  under  surface  of  the  stricture  as  preferred. 

Harrmrnh  Urethrotome. — This  also  cuts  from  without  inwards,  but 
on  a  different  plan  ;  this  instrument  ending  in  a  catheter-like  ex- 
tremity and  thus  dispensing  with  the  filiform  guide-bougie.  Such  a 
pattern  will  be  preferred  by  many  surgeons,  especially  l)y  those  who 
use  fine  metallic  instruments  in  dilating  strictures.  The  anterior 
part  of  Mr.  Harrison's  urethrotome  is  sufficiently  small  to  ])ass  into 
the  narrowest  strictures,  behind  this  is  a  broad  portion  equal  to  a  No. 
10  bougie,  and  terminating  anteriorly  in  an  abrupt  shoulder.  Within 
this  broad  portion  is  contained  a  lancet-shaped  knife,  which  is  made 
to  project  by  a  spring  in  the  handle  and  to  run  along  a  slit  in  the 
narrow  part  of  the  instrument.  The  extent  to  which  the  blade  can 
be  projected  is  regulated  by  a  screw.  When  the  instrument  is  passed 
down  the  urethra,  the  position  of  the  stricture  is  indicated  by  the 
broad  shoulder,  against  which  it  is  pressed  firmly  as  with  S3mie's 
staff.  The  position  of  the  stricture  being  thus  ascertained  and  fixed 
by  the  shoulder,  the  knife  is  projected  and  the  stricture  divided. 
The  knife  being  withdrawn,  if  the  stricture  has  been  completely 
divided,  the  broad  shoulder  passes  on  readily  into  the  bladder.  The 
stricture  is,  by  this  instrument,  divided  above  and  belovv.  Dilatation 
is  maintained  by  the  passage  of  laterally  oval  liougies. 

B.  Those  cutting  from  within  outwards. — A  good  represen- 
tative of  these  instruments  is  Sir  H.  Thompson's  modification  of 
Civiale's  urethrotome.  This  has  a  bulbous  extremity,  from  which  the 
blade  is  protruded.  The  stricture  being  sufficiently  dilated  to  admit 
a  No.  4  or  5  bougie,  the  bulb  (which  forms  a  useful  sound)  is  carried 

*  If  it  is  doubtful  vvlietlier  the  guide  has  reached  the  bladder,  Mr.  Hill  adviries  to 
screw  on  a  No.  \  flexible  catheter  to  the  guide,  and  to  pnsh  the  whole  onwards  till 
the  catheter  has  passed  8  inches  inwanls.  A  small  exhausting  syringe  is  tiien  applied 
to  the  catheter,  and  a  few  drops  of  urine  drawn  through  it. 

t  The  meatus  must  be  divided,  if  too  small  to  admit  the  wedge. 

X  After  the  first  cut  the  knife  i-<  withdrawn  within  the  wedge,  and  only  protruded 
when  a  tight  band  opposes  the  free  passage  of  the  wedge. 


liSTERXAL   URETHROTOMY.  795 

about  i  inch  beyond  the  stricture,  the  knife  projected,  and  the  in- 
cision made  by  draAving  it  slowly  and  firmly  outwards — to  the  dis- 
tance of  ^  to  2  inches — generally  along  the  floor  of  the  urethra,  so  as 
to  incise  the  stricture  freely.  A  metallic  bougie  is  then  passed,  and 
if  at  any  point  it  is  held  closely,  there  is  still  almost  certainly  some 
spot  which  needs  toucliing  with  the  blade. 

After-treatment. — This  varies  very  much.  Some  surgeons — e.g.. 
Sir  H.  Thompson  and  Mr.  Harrison — pass  at  once  and  tie  in  a  full- 
sized  catheter  for  twenty-four  or  forty-eight  hours,  passing  after  this  a 
full-sized  instrument  at  intervals.  Others — 6,(7.,  IMr,  B.  Hill — draw  off 
the  urine  with  a  full-sized  catheter,  after  division  of  the  stricture,  but 
tie  none  in.  The  patient  is  ordered  not  to  micturate  for  seven  or  eight 
hours  if  possible.  By  this  time  the  incision  is  protected  by  clot  and 
plastic  lymph,  and  when  tlie  bladder  must  be  emptied,  the  patient 
passes  water  in  a  hot  V)ath,  all  pain,  spasm,  and  risk  of  tearing  open 
the  wound  being  thus  avoided.  The  patient  is  kept  in  bed  for  ten 
days,  and  about  the  eighth  day  a  full-sized  bougie  is  passed,  this 
period  of  rest  being  insisted  upon  to  avoid  pain,  bleeding,  and  sup- 
puration. 

Comparison  of  the  two  Methods  of  Internal  Urethrotomy. 
— With  the  instruments  which  cut  from  without  inwards,  and  guided 
by  a  filiform  bougie,  narrower  strictures  can  be  attacked  than  by  the 
bulbous-ended  urethrotome,  cutting  in  the  reverse  direction.  These 
latter  have  been  recommended  as  having  the  advantage  of  steadying 
the  fibres  to  be  cut  by  their  pulling  forwards  the  parts  which  attach 
the  urethra  to  the  pelvis,  as  the  bulbous  end  of  the  instrument  is 
drawn  out.  The  stricture  is  thus  pulled  on  by  the  instrument  until 
the  divided  stricture  gives  free  passage  to  the  bulbous  shield  and  the 
knife  protruded  from  it.  Mr.  B.  Hill,  however,  considers  that  "  re- 
liance cannot  be  placed  on  the  simple  straining  of  these  attachments 
ensuring  perfect  division  of  the  stricture-tissue.  A  Civiale^s  or  any 
other  urethrotome  which  cuts  from  within  outwards  is  very  apt  to 
wriggle  its  way  through  a  stricture,  only  scoring  it,  but  not  j>erfectly 
severing  its  fibres,  and  to  meet  this  difficulty  the  knife  is  often  carried 
more  deeply  than  is  necessary."  Mr.  Hill  further  believes  that  by 
cutting  from  without  inwards  there  is  less  risk  "  of  making  an  incision 
through  a  thin  layer  of  fibrous  tissue  into  erectile  tissue,  in  the  belief 
that  a  thick  layer  of  fibrous  tissue  exists,"  and  thus  of  causing  free 
haemorrhage. 

While  myself  usually  practicing  what,  on  the  whole,  I  believe  to  be 
preferable,  continuous  dilatation  aided,  if  need  be,  by  external  urethrot- 
omy such  as  Prof.  Syme's  operation,  I  have,  I  trust,  here  freely  dealt 
with  internal  urethrotomy.  Before  leaving  this  matter  I  should  like 
to  allude  to  the  question  of  time.     Internal  urethrotomy  no  doubt 


796  OPERATIONS  ON  THE  ABDOMEN. 

saves  time  and  trouble  also,  but  it  must  not  be  thought  that  the 
saving  is  such  a  very  large  one.  Thus,  with  regard  to  time,  Mr. 
B.  Hill  writes  :*  "  It  is  indispensable  that  the  patient  lie  in  bed 
continuously  for  at  least  ten  days,  arid  keep  his  room  for  fourteen 
days."  Subsequent  regular  passage  of  a  bougie  is  as  needful  after 
internal  urethrotomy  as  any  other  mode  of  treating  stricture. 

ECTOPIA  VESICAE  AND  EPISPADIAS. 

Owing  to  the  misery  which  this  condition  entails  the  surgeon  may 
always  1je  ready  to  operate  in  the  hope,,  at  least,  of  making  the  wear- 
ing of  a  urinal  easy  and  efEcient,  if  he  cannot  secure  the  formation 
of  a  sufficient  cavity  to  retain  fluid;  at  the  same  time,  from  the  con- 
traction resulting  froni!  liis  operation,  a  partial  or  complete  cure  of 
the  herniae,  which  not  unfrequently  accompany  tliis  malformation, 
may  be  secured. 

Age. — The  cure  of  the  ectopia  may  be  commenced  after  the  child  is 
four  or  five,  and  should,  be  completed,  if  possible,  by  puberty.  In 
this  case  the  epispadias  niiiy  be  taken  in  hand  and  completed  before 
adolescence,  when  the  growth  of  hairs  and  sexual  desires  will  inter- 
fere much  with  the  union  of  the  flaps. 

Unfavorable  Conditions,  t 

1.  Large  size  of  the  ectopia,  with  much  bleeding  and  some  puru- 
lent discharge  from  the  surface. 

2.  A  sickly  condition  of  the  patient,  pointing  to  poor  powers  of 
repair,  and  a  waddling  gait  to  wide  separation  of  the  pubes. 

3.  Tendency  to  cough.     This  increases  the  protrusion. 

4.  Presence  of  large  hernia. 

5.  Secondary  dilatation  of  the  ureters  and  pelvis  of  the  kidney, 
with  degeneration  of  this  viscus.| 

6.  Obstinate  eczematous  rawness. 

7.  Small  size  of  the  scrotum.     This  is  rare. 

Preparatory  Treatment. — If  the  patient  has  passed  puberty, 
and  the  hair  is  at  all  abundant,  depilation  should  be  practiced,  and 
nitric  acid  applied  at  intervals  to-  the  groups  of  hair- follicles. 

It  may  be  well  also  to  try  and  diminish  the  size  of  the  ectopia  by 
the  means  adopted  by  Mr.  Greig  Smith  who,  for  some  weeks  previous 

*  Diet,  of  Su7-g.,  vol.  ii.  p.  729.  See  also  the  Lectures,  alike  candid  and  helpful  in 
detail,  by  the  same  surgeon  {Brit.  Med.  Joiirn.,  1879,  vol.  ii.  pp.  7G3,  et  seq.). 

t  For  full  information  on  all  these  matters  Mr.  J.  Wood's  articles  (Diet,  of  Surg,, 
vol.  i.  p.  425,  and  Med.  Chir.  Trans  ,  vol.  Hi.  p.  85)  should  be  consulted. 

X  Mr.  Wood  {loe.  supra  cit.)  shows  that  sometimes  the  above  complication  may  be 
recognized  by  the  presence  of  more  albuminuria  than  is  accounted  for  by  the  amount 
of  cystitis.  In  other  cases,  no  such  signs  are  |>resent.  Out  of  forty  cases,  a  fatal  result, 
chiefly  from  tliis  cause  and  undetected,  followed  in  four  cases. 


ECTOPIA    VESICA    AND    EPISPADIAS.  797 

to  operation,  kept  the  patient  on  his  back,  and  the  exposed  mucous 
membrane  protected  with  green  protective  coated  with  dextrine, 
covering  this  over  with  boracic  h'nt,  and  by  this  means,  in  one 
case,  the'  mucous  membrane  not  only  became  less  angry,  but  its 
upper  half,  almost  as  low  as  the  ureters,  became  covered  with  epi- 
dermis almost  as  white  as  the  surrounding  skin.* 

Operation  — An  ansesthetic  being  given,  a  median  flapf  is  raised 
from  the  abdominal  wall  above  the  exposed  bladder.  Its  shape  re- 
sembles that  of  the  wooden  portion  of  a  fire-bellows,  its  length  i-s 
rather  greater  than  the  distance  between  the  root  of  the  penis  and  the 
upper  margin  of  the  exposed  bladder,  Avhile  its  root  must  be  suffi- 
ciently broad  to  ensure  a  sufficient  blood-supply.  In  raising  it.  care 
must  be  taken  not  to  cut  it  too  thin,  and,  at  the  same,  not  to  go  too 
deeply  with  the  point  of  the  knife,  as  the  tissues  here  are  extremely 
thin,  and  the  flat,  tense,  expanded  linea  alba  beneath  is  often  very 
thin,  and  thus  the  peritoneal  cavity  may  easily  be  opened. 

The  two  groin  flaps  are  next  made  of  rounded-oval  shape,  with 
broad  pedicles,  the  outer  boundar}^  of  which  is  sufficiently  carried 
out  on  to  the  thigh,  and  then  on  to  the  root  of  the  scrotum,  to  ensure 
its  containing  the  superficial  epigastric  and  the  external  pudic  arteries. 
The  inner  rhargins  of  these  flaps  join  those  for  the  central  flap  at 
about  its  centre,  and  are  then  continued  down  along  the  side  of  the 
urethral  groove  for  about  half  its  length. 

While  these  flaps  must  be  cut  as  thick  as  possible,  care  must  be 
taken  to  avoid  any  subsequent  hernise,  and  they  must  be  sufficiently 
detached  to  meet  for  their  whole  length  without  tension  in  the  middle 
line.  In  raising  them  they  must  be  handled  as  carefully  as  possible, 
whether  with  fingers  or  with  bluntly  serrated  forceps,  so  as  in  no  way 
to  impair  their  vitality.  All  bleeding  being  stopped,  the  flaps  being 
washed  with  boracic-acid  lotion,  and  their  surfaces  allowed  to  become 
glazed.|  the  umbilical  flap  is  first  taken  and  folded  down,  with  it« 
skin  surface  towards  the  bladder,  evenly  and  without  tensiom  It  is 
then  stitched  to  the  cut  edge  at  the  root  of  the  penis. 

The  groin  flaps  are  then  drawn  inwards,  placed  with  their  raw  sur- 
faces upon  the  raw  surface  of  the  umbilical  flap,  and  carefully  stitched 
together.  The  sutures  should  be  many  and  mixed,  of  wire,  carbolized 
silk,  fishing-gut,  and  horsehair.    Wire  has  th«  advantage  of  being  non- 

*  In  anotlier  ca^e,  also  siicces«fiilly  operated  on,  no  prelkninaTy  treatment  was  of 
any  avail  in  diminishing  tlie  size  of  tlie  eclopia. 

t  The  shape  and  arrangement  of  the  flaps  is  excellently  shown  in  pi.  ii.  Figs.  1  and 
2  aoeonipanying  Mr.  Wood's  paper  [Med.-Chir.  Trav.t.,  vol   lii.). 

X  Spencer  Wells's  forceps  should  be  left  on  for  five  or  len  minutes  to  any  bleeding 
points,  and  all  ligatures,  even  of  fine  chromic  ^ut^  disj)eivsed  \vitl\,  if  possilile.  Oozin" 
will  yield  to  firm  sponge-prjessiir.e> 


798  OPERATIONS    OX    THE   ABDOMEN. 

irritating  and  of  keeping  sweet  in  a  wound  which  cannot  be  kept  aseptic. 
The  sutures  should  be  left  in  for  a  fortnight,  and,  in  the  case  of  chil- 
dren, it  may  be  well  to  give  an  ansesthetic  to  take  them  out. 

The  raw  surface  from  which  the  central  flap  Avas  taken  is  then 
closed,  as  far  as  possible,  with  long  hare-lip  |)ins  and  twisted  sutures, 
but  the  object  here  must  be  rather  to  take  tension  off  the  flaps  than  to 
completely  close  this  wound. 

The  parts  are  then  painted  with  collodion  and  iodoform,  and  sal 
alembroth  gauze  applied,  and  the  biattocks  and  hips  smeared  with 
eucalyptus  and  vaseline.  If  any  redness  appear,  wet  boracic-acid  lint 
elressings  should  be  made  use  of. 

After-treatment. — The  patient  must  be  kept  partly  sitting,  the 
shoulders  being  well  propped  up  and  the  knees  flexed ;  a  bandage 
passed  from  the  knees  around  the  shoulders  will  facilitate  this.  Any 
sudden  straightening  of  himself  by  the  patient  is  fatal  to  a  good 
result.  For  the  first  few  days  small  opiates  or  injections  of  morphia 
will  be  required. 

HYPOSPADIAS. 

It  is  impossible  in  a  work  like  this  to  describe  the  operations  for 
this  fully.  I  have  only  space  to  allude  to  some  practical  points  which 
may  be  useful  to  a  surgeon  when  consulted  about  the  advisability  of 
an  operation. 

Varieties. — These  are  three,  viz. : 

1.  Glandular. — The  opening  is  here  merely  further  back  than  usual, 
the  frffinum  is  absent,  the  glans  broad,  flattened,  somewhat  recurved, 
and  the  prepvice,  often  hood-like,  always  in  a  condition  of  partial 
paraphimosis. 

2.  Penile. — Here  the  urethra  is  especially  liable  to  open  at  one  of 
the  three  following  sites:  (a)  Just  behind  the  glans;  (b)  at  the  middle 
of  the  penis;  (c)  at  the  junction  of  the  penis  and  scrotum. 

3.  Scrotal.* — Here  the  cleft  on  which  the  urethra  opens  may  be 
either  at  the  junction  of  the  penis  and  scrotum,  or  involve  the  scrotum 
and  perineum,  the  former  being  called  peno-scrotal,  and  the  latter 
perineo-scrotal. 

When  an  operation  is  under  consideration,  wdth  a  view  of  rendering 
micturition  and  coitus  normal,  the  surgeon  must  take  into  due  con- 
sideration— («)  the  degree  of  the  deformity  ;  (ft)  whether  the  penis  is 
fairly  developed;  (y)  whether  it  is  much  tied  down;  (S)  whether  the 
testicles  are  present  and  descended  ;  (?)  how  far  the  patient's  condition 
is  made  miserable  by  rawness  and  eczema  due  to  impeded  micturition, 
and  by  impeded  coitus ;  and  bow  far  there  are  reasonable  hopes  of 
restoring  these. 

*  The  above  is-souietiu)es  (ILvkled  Into  two,  scruuiLy.iwl  peinneo-scrotal. 


HYPOSPADIAS.  799 

Operation. — I  shall  describe  here  that  of  M.  Duplay,  of  the  Lari- 
boisiere  Hospital.  He  divides  the  restoration  into  the  following  three 
stages,  Avhich  require,  in  order  to  be  successful,  much  time  and  pa- 
tience on  the  part  of  both  surgeon  and  patient : 

i.  Straightening  the  penis  and  formation  of  a  meatus;  ii.  Formation  of  a 
canal  from  the  meatus  to  the  hypospadiac  opening  ;  iii.  Junction  of  the  old 
and  neiv  canal. 

i.  Straightening  the  Penis. — In  the  penile,  peno-  and  perineo-scrotal 
varieties,  the  penis,  often  short,  is  recurved,*  especially  during  erection, 
by  a  band  consisting  partly  of  a  muco-cutaneous  ridge,  corresponding 
to  the  absent  urethra,  and  reaching  from  the  hypospadiac  orifice  to 
the  glans.  M.  Bouisson  seems  to  have  first  pointed  out  the  importance 
of  dividing  this,  which  he  did  subcutaneously  (p.  800).  M.  Duplay 
recommends  division  by  an  open  wound,  carrying  the  incision  as 
deeply  as  needful,  and  states  that  the  corpora  cavernosa  may  be  in- 
cised to  a  ver}^  considerable  depth,  if  needful  to  secure  this  end. 

At  the  same  time  the  above-named  surgeon  forms  a  meatus.  This 
is  done  by  paring  the  two  lips  of  the  depression  which  represents  the 
meatus,  and  uniting  these  over  a  bit  of  catheter.  If  the  depression  be 
very  shallow,  an  incision  upward  into  the  glans-tissue,  or  two  lateral 
ones,  maj'  be  needed  before  it  is  possible  to  insert  a  catheter,  and  to 
apph'  sutures  round  it. 

ii.  Formation  of  a  New  Urethra.'\ —Th.Q  penis  being  held  up,  two 
incisions  are  made  a  little  outside  the  lateral  margins  of  the  mucous 
surface  corresponding  to  the  deficient  urethra,  and  reaching  from  the 
glans  to  the  hypospadiac  orifice.  B}^  making  two  transverse  incisions 
at  either  end,  two  narrow  quadrilateral  flaps|  are  dissected  up  towards 
the  middle  line  until  with  their  mucous  surfaces  turned  inwards  and 
their  raw  surfaces  outwards,  the}'  meet  without  tension  over,  and  thus 
shut  in  a  catheter  passed  from  the  previously  restored  meatus  to  the 
hypospadiac  orifice.  These  flaps  are  now  united  with  sutures,  partly 
of  fine  chromic  gut  and  partly  of  fine  carbolized  silk,  cut  quite  short. 
From  the  sides  of  the  penis  two  similar  flaps  are  dissected  up  from 
within  outwards,  till  they  can  be  sufficiently  drawn  inwards  without 
tension  to  cover  over  the  raw  surfaces  of  the  internal  flaps.  They  are 
then  carefully  united  in  the  middle  line.  I  much  prefer  horsehair  and 
fishing-gut  sutures  here,  well  soaked  previously  in  warm  carbolic  acid. 

M.  Duplay  uses  silver  wire,  and  to  prevent  the  sutures  cutting 

*  This  recurving  is  also  in  part  clue  to  thickening  and  shortening  of  the  capsule  of 
the  corpora  cavernosa,  and  even  of  the  septum. 

+  Several  months,  at  least  five  or  six,  must  elapse  before  the  surgeon  is  certain  that 
no  recurving  will  occur.     Tiiis  disappears  very  gradually. 

X  The  formation  of  these  flaps  is  well  shown  in  Fig.  1349  in  M.  Duplay's  article 
{Intern.  Encycl.  of  Surg.,  vol.  vi.  p.  500). 


800  OPERATIONS    OX   THE    ABDOMEN. 

through  during  erections,  etc,  he  passes  them  through  small  leaden 
perforated  tubes,  fixing  the  sutures  with  shot.  Whichever  method  is 
used  the  sutures  should  be  fine,  and  put  in  sufficiently  close  to  dis- 
tribute the  tension,  but  not  too  numerously,  or  tied  too  tightly,  which 
will  cause  sloughing. 

iii.  Joining  the  Old  and  New  Urethra. — As  soon  as  the  new  urethra  is 
thoroughly  established,  tjuite  closed,  and  shows  no  sign  of  contraction, 
this  Inst  stage  may  be  undertaken.  The  edges  of  the  posterior  end  of 
the  new  urethra  and  those  of  the  remaining  orifice  having  been  freely 
vivified,  and  a  catheter  passed  from  the  meatus  into  the  bladder,  the 
opening  is  closed  over  it  by  sutures  as  in  stage  ii.  A  catheter — one  of 
Jaques's  pattern  is  least  painful — should  be  kept  in  the  bladder  if  pos- 
sible, till  all  is  water-tight. 

EPISPADIAS. 

I  am  unable  to  find  space  for  any  really  full  account  of  the  different 
attempts  to  cure  this  rare  condition.  For  some  points  of  j^ractical  im- 
portance I  would  refer  my  readers  to  the  remarks  on  hypospadias 
(p.  798). 

Any  attempt  at  curing  epispadias  should  be  divided  into  three 
stages,  thus : 

i.  Straightening  the  Penis. — While  the  penis  is  short,  recurved,  so  as 
to  lie  in  contact  with  the  abdominal  wall,  it  is  no  use  trying  to  com- 
plete the  defective  urethra.  Attempts  should  be  made  to  straighten 
the  penis  by  dividing  it  subcutaneously  close  to  the  pubes,  each  corpus 
cavernosum  being  cut  separately.  In  the  only  case  in  which  I  prac- 
ticed this,  in  a  patient  aged  seventeen,  the  hf^emorrhage  was  easily  con- 
trolled by  dry  gauze  and  light  pressure,  but  very  sharp  tenotomes 
must  be  employed,  as  the  erectile  tissue  offers  much  less  resistance 
than  a  tendon.  Each  corpus  cavernosum  should  be  divided  com- 
pletely, and  as  cleanly  as  possible.  The  penis  must,  for  some  time, 
be  kept  fastened  down,  improvement  in  its  position  takes  place  grad- 
ually, together  with  increase  in  its  length,  this  being,  eventually,  more 
marked  the  earlier  the  operation  is  performed. 

ii.  Covipletion  of  Deficient  Urethra  from  the  Meatus  to  the  Eplspadiac 
Opening. — The  simplest  way  of  effecting  this  is  by  the  method  of 
Thiersch  and  Duplay,  much  as  in  hypospadias,  to  the  account  of 
which  I  would  refer  my  readers.  Two  narrow  quadrilateral  flaps  ex- 
tending from  the  meatus  to  the  epispadiac  orifice  are  marked  out  and 
dissected  up  from  without  inwards  on  either  side  of  the  open  urethra, 
both  being  left  attached  in  the  middle  line.  These  turned  with  their 
muco-cutaneous  surface  inwards,  over  a  small  Jaques's  catheter,  to  form 
the  new  urethra,  and  their  raw  surfaces  outwards,  are  united  in  the 
middle  line  with  numerous  points  of  sutures  cut  short  and  buried  (p. 


CIRCUMCISION.  801 

799).  Thin  flaps  dissected  up  from  within  outwards  from  off  the 
dorsum  and  sides  of  the  penis  are  then  drawn  inwards,  raw  surfaces 
being  thus  opposed  to  raw  surfaces,  and  kept  h^  situ  by  numerous 
points  of  sutures. 

iii.  Junction  of  the  Old  and  Xew  Canal  by  Closure  of  the  Epispadiac 
Opening. — This  is  effected  by  freely  refreshing  the  surrounding  parts 
and  suturing  them  carefully.  Before  the  union  is  complete,  several 
operations  may  be  required,  both  for  this  condition  and  hypospadias. 

CIRCUMCISION. 

Trivial  as  this  operation  seems,  it  is  so  important,  especiall}^  in 
adults,  to  secure  speedy  healing,  that  it  will  be  briefly  alluded  to  here. 

Indications. — This  operation  is  still  not  practiced  often  enough, 
especially  amongst  poorer  patients,  amongst  whom  many  practitioners 
still  treat  phimosis  as  a  matter  of  but  little  importance.  Hospital 
surgeons  have,  only  too  often,  opportunities  of  seeing  the  following 
results  follow  from  the  above  course:    (a)  Balanitis  and  adhesions. 

(b)  Paraphimosis,  from  the  forcible  retraction  of  a  phimosed  prepuce. 

(c)  From  the  impediment  to  micturition,  urethral  and  vesical  irritation 
and  even  cystitis  may  be  set  up,  simulating  the  symptoms  of  stone. 
{d)  Prolapsus  recti  and  hernia,  (e)  The  sexual  feelings  too  early 
induced,  and  bad  habits.  (/)  Impediments  to  intercourse,  (g)  Inten- 
sified gonorrhcEa,  chancres,  etc.     (h)  Epithelioma.^ 

Operation. — This  may  be  jDerformed  in  many  different  ways,  but 
the  following  points  must  be  remembered  in  every  case  :  (1)  To  remove 
enough  of  the  mucous  layer  of  the  prepuce.  If  this  be  not  done,  some 
tension  on  the  glans  remains,  and  this  leads,  especially  in  adults,  to 
troublesome  erections  which  interfere  very  much  with  the  23rocess  of 
healing ;  later  on,  some  degree  of  phimosis  is  certain  to  persist.  (2) 
Not  to  leave  too  much  tissue  about  the  frrenum.  Mr.  Howsef  has 
drawn  attention  to  the  fact  that  the  cellular  tissue  at  this  spot  is  loose, 
and  that  the  presence  of  the  frsenal  artery  makes  probable  the  gather- 
ing of  blood  and  inflammatory  efl'usion  at  this  spot.  In  children  this 
is  a  matter  of  less  importance,  but  in  adults  it  may  lead  to  the  forma- 
tion of  a  tediously  persistent  lump,  interfering  with  the  function  of 
the  organ.  (3)  Not  to  remove  too  much  of  the  prepuce.  Thus,  it  is 
always  Avell,  in  adults  especially,  to  leave  enough  to  cover  easily  the 
sensitive  papillte  with  which  the  corona   abounds.     Again,  in  the 

*  Prof.  Sayre  {Orthopcrdk  Surgeru,  p.  1-1)  describes  cases  in  which  paralysis  of  cer- 
tain groups  of  muscles,  leading  to  talipes  and  other  deformities,  followed  on  early 
sexual  excitement,  due  to  phimosis.  See  also  the  case  recorded  by  Mr.  Hilton  {Rest 
and  Pain,  p.  276 1. 

t   Guy's  Hosp.  Reports,  1873,  p.  239. 

51 


802  OPERATIONS   ON    THE    ABDOMEN. 

diminutive  organ  of  infants,  it  is  very  easy  to  remove  so  much  as  to 
flay,  in  part,  the  body  of  the  organ. 

The  following  is  a  very  simple  mode  of  operating  :  The  prepuce 
having  been  separated  as  much  as  possible  from  the  glans  with  the 
finger  and  thumb,  or  a  stout  probe,  a  pair  of  dressing-forceps  is  lightly 
placed  on  the  penis  at  a  level  with  the  corona ;  the  glans  being  allowed 
to  slip  back,  the  forceps  are  closed,  and  all  the  prepuce  in  front  of  the 
instrument  is  cut  off  with  a  sharp  scalpel  used  with  a  rapid  sawing 
movement.  The  blades  being  at  once  removed,  the  mucous  membrane 
is  then  slit  up  with  a  director  and  scissors  or  a  sharp-pointed  bistoury,* 
this  incision  running  up  to,  but  not  beyond,  the  corona.  The  mucous 
membrane,  if  still  adherent,  is  then  peeled  in  two  flaps  from  off'  the 
glans,  this  detachment  being  affected  by  the  finger  and  thumb,  or  by 
a  stout  probe  swept  round.  The  cut  edges  of  the  prepuce  are  then 
rounded  ofT  with  scissors,  which  follow  the  curve  of  the  glans  as  far  as 
the  frajnum,  the  prepuce  being  left  attached  here.  Enough  prepuce 
should  be  left  to  cover  over  the  corona-papillfe,  and  to  admit  of  easy 
stitching.  Chromic  gut  and  horsehair  make  the  best  sutures.  Very 
fine  needlea  should  be  used,  and  the  sutures  passed  quickly  through 
skin  and  mucous  membrane  with  a  stabbing  movement,  and  without 
bruising  the  edges  with  forceps.  In  passing  the  sutures  any  bleeding- 
points  must  be  transfixed,  and  the  abundant  cellular  tissue!  kept  in 
its  place  with  the  point  of  a  probe.  The  frfenum  is-  now  attended  to, 
the  prepuce  which  is  still  attached  here  being  cut  away  carefully  by 
Y-shaped  cuts,  pointing,  forwards,  and  leaving  just  enough  flaps  to 
carry  the  sutures  and  no  more.  The  frrenal  artery  can  usually  be 
secured  by  transfixing  it  Avith  one  of  the  sutures,  if  not,  it  is  readily 
tied  with  a  fine  chromic-gut  ligature. 

I  much  prefer  interrupted  sutures  of  the  above-given  materials  for 
circumcision ;  a  continuous  suture  often  gives  good  results  in  healthy 
subjects,  but  the  former  have  the  great  advantage  that  one  or  two  can 
be  removed  without  interfering  with  the  rest. 

For  adults,  one  of  the  two  following  dressings  will  be  found  the 
best.  When  the  parts  are  at  all  swollen  or  where  erections  are  likely 
to  be  troublesome,  I  use  boracic-acid  dressings,  two  layers  of  boracic- 
acid  lint  wrung  out  of  a  saturated  solution  of  the  lotion.  The  deeper 
layer  has  a  hole  cut  to  allow  of  micturition  and  is  only  removed  by 
the  surgeon,  the  outer  one  envelops  the  whole  penis,  and  may  be 

*  It  is  well  at  this  stage  to  make  tension  on  the  loose  prepuce  with  two  pairs  of 
dissecting  forceps,  and  thus  secure  a  clean  section. 

f  This  must  on  no  account  be  cut  away,  as  in  it  run  the  vessels  to  tiie  prepuce.  All 
bleeding  must  be  stopped,  especially  in  adults,  or  extravasation  of  blood  in  the  loose 
connective  tissue  leads  to  tension,  cutting  through  of  sutures,  or  sloughing. 


AMPUTATION    OF    THE    PENIS.  803 

removed  and  re-wetted  by  the  patient  from  time  to  time,  though 
usually  it  is  sufficient  for  him  to  keep  it  wet  by  dro]3ping  on  a  little 
lotion  from  time  to  time  * 

After  circumcision  the  patient  should  rest  as  much  as  possible.  Thus, 
an  adult  should  stay  in  bed  for  forty-eight  hours,  and  keep  on  the 
sofa  for  a  week,  alternate  stitches  being  removed  at  intervals.  If  he 
insist  on  getting  about  too  early,  he  must  run  the  risk  of  the  parts 
remaining  long  oedematous  and  tender.  And  for  this  reason,  with 
hospital  patients  who  have  to  come  backwards  and  forwards,  early  and 
complete  healing  is  not  to  be  expected. 

AMPUTATION  OF  THE  PENIS  (Fig.  132). 

Indication, — Epithelioma  of  penis.  I  would  refer  my  readers  to 
the  remarks  made  at  p.  326  on  the  pre-cancerous  stage  in  epithelioma 
of  the  tongue.  Though  epithelioma  of  the  penis  is  much  less  common, 
lives  are,  here  also,  too  often  lost  by  allowing  the  case  to  get  beyond 
this  stage.  Any  suspicious  excoriation,  ulceration,  or  wart  should  be 
early  destroyed  with  the  acid  nitrate  of  mercury  or  excised.  Where, 
after  this  treatment,  satisfactory  healing  does  not  take  place,  early  and 
thorough  removal  of  the  part  should  be  performed.  There  should  be 
no  dangerous  waiting,  because  the  surgeon  is  unable  to  satisfy  himself 
whether  the  case  is  one  of  inflammatory  induration  or  infiltration  from 
new  growth.  In  such  cases,  especially  where  there  is  a  doubtful  his- 
tory of  syphilis,  much  valuable  time  has  been  often  lost  with  drugs, 
which,  even  if  the  lesion  does  date  back  to  some  long-past  syphilis,  are 
quite  useless  if  epitheliomatous  ulceration  has  set  in.  Furthermore, 
the  longer  ulceration  continues,  the  more  extensively  will  the  inguinal 
glands  be  involved.  In  such  cases,  though  the  penis  may  be  satis- 
factorily operated  upon,  disappointment  will  speedily  follow,  owing  to 
the  outbreak  in  the  inguinal  regions.  It  may  be  added  that  scarcely 
any  surgical  case  presents  a  close  more  distressing,  both  to  the  patient 
and  those  around  him,  than  one  of  breaking  down  of  epitheliomatous 
glands,  owing  to  the  hideous  ulceration,  the  noisome  discharge,  and 
the  steady  decay  of  bodily  strength. 

In  a  very  few  cases,  when  the  disease  commences  around  the  meatus, 
it  may  still  be  possible  to  remove  the  affected  part  without  interfering 
with  the  body  of  the  penis.  It  seldom  happens,  however,  that  we  see 
the  case  early  enough  for  this,  and  it  is  usually  necessary  to  remove 

*  Mr.  Ballance  {St.  Thoviaa's  Hosp.  Reports,  vol.  xvi.  p.  198)  advises  a  dry  dressing 
ot"  gauze,  the  outer  and  larger  covering  being  of  a  single  layer,  and  its  margins  kept  in 
position  by  collodion.  This  simple  and  ingenious  mode  of  dressing  will  be  found  most 
effective  in  a  very  large  number  of  cases  besides  circumcision — e.g ,  amputations, 
removal  of  breast,  partial  thyroidectomy,  etc.  In  addition  to  the  above  advantages,  it 
is  cool  and  light,  dispensing,  as  it  does,  with  bandages,  and  inexpensive  as  well. 


804  OPERATIONS  OX  THE  ABDOMEN. 

the  whole  of  the  glans  and  more  or  less  of  the  corpora  cavernosa. 
Before  doing  this,  tlie  prepuce,  unless  it  admits  of  being  retracted, 
should  invariably  be  laid  open,  so  as  to  expose  the  growth  and  make 
quite  sure  of  its  real  nature. 
Operations. 

I.  Galvanic  Cautery. — I  am  as  much  against  this  method  here 
as  in  tlie  case  of  the  tongue  (p.  338).  The  dread  of  haemorrhage  still 
induces  some  to  resort  to  it ;  it  is  not,  however,  a  sure  preventive. 
Sharp  bleeding  has  followed  a  few  hours  after  the  operation,  and  also 
later  on  during  the  detachment  of  sloughs  ;  furthermore,  this  operation 
leaves  a  much  more  troublesome  and  sloughy  wound  than  the  knife. 
This  may  be  a  matter  of  but  slight  importance  in  patients  who  are 
comparatively  young  and  robust,  but  where,  as  frequently  happens 
with  these  patients,  they  are  advanced  in  years  or  prematurely  aged, 
pulled  down  in  health,  and  often  dei)ressed  in  mind,  tedious  healing 
of  the  wound  (which  it  is  difficult  to  keep  sweet),  involving,  as  it  does, 
a  prolonged  keeping  the  patient  on  his  back,  with  the  risks  of  broncho- 
pneumonia, erysipelas,  etc.,  is  not  a  light  matter.  The  need  of  a 
special  expensive  instrument,  and  the  unpleasant  foetor  of  the  operation, 
are  also  objections. 

If  the  surgeon  make  use  of  it,  a  No.  4  or  6  catheter  should  first  be 
passed ;  the  loop  of  wire  is  then  tightened  around  the  penis,  well 
behind  the  disease,  and  kept  there  by  one  or  two  pins.  When  the 
current  is  passed,  care  must  be  taken  that,  by  tightening  the  wire  very 
slowly,  and  watching  the  amount  of  heat,  the  vascular  structures  are 
not  severed  too  quickly  ;  otherwise  haemorrhage,  very  difficult  to 
arrest  on  a  seared  surface,  is  certain  to  follow.  The  catheter  is  cut 
through  by  the  heated  wire,  and  the  urethra,  thus  maintained  patent, 
is  slit  up  and  stitched  as  directed  below. 

II.  Circular  Amputation  of  Penis.— This  method  gives  good 
results,  though  not  equal,  in  my  opinion,  to  those  which  follow  on  the 
flap  method.  The  vessels  being  commanded  by  a  clove-hitch,  or  by 
the  clamp  which  bears  Mr.  Clover's  or  Mr.  Durham's  name,  the  skin 
is  drawn  a  little  forward  to  prevent  any  superabundance  afterwards, 
and  the  amputation  is  effected  by  a  single  sweep  of  the  knife.  The 
vessels  and  the  urethra  are  treated  as  directed  below. 

III.  Flap  Amputation  (Fig.  132). — This  method  has  been  fol- 
lowed by  rapid  healing,  and  has  given  an  excellently  covered  stump 
in  the  four  cases  in  which  I  have  made  use  of  it.  Hsemorrhage  being 
provided  against  by  one  of  the  above-given  means,  the  surgeon  enters 
a  narrow-bladed  knife,  at  a  point  well  behind  the  disease,  between 
the  corpus  spongiosum  and  the  corpora  cavernosa,  and  then  cuts 
forwards  and  downwards  for  about  I  inch.     From  this  small  inferior 


AMPUTATION    OF    THE    PENIS.  805 

flap  the  urethra  is  dissected  out.  A  flap  of  skin  is  now  cut  from  the 
dorsum  and  sides  of  the  penis,  resembling  in  miniature  the  upper 
skin-flap  in  amputation  of  the  thigh.  This  flap  being  held  back,  the 
corpora  cavernosa  are  divided  vertically  upwards  on  a  level  with  the 
point  of  transfixion.  Any  vessels  which  can  be  seen  are  now  tied 
with  chromic  gut  or  carbolized  silk.     On  removal  of  the  clamp  or 

Fig.  132. 


Flap  amputation  of  the  penis.  Tlie  appearance  of  the  stump,  with  the  urethra  slit  up  and 
stitched  m  situ  is  shown  above.  The  raw  surface  from  which  the  dorsal  flap  has  been  raised 
should  have  been  shown  in  the  lower  figure. 

clove-hitch,  and  securing  any  spirting  vessels,  free  oozing  often  per- 
sists for  a  few  minutes,  but  ceases  spontaneously.  All  haemorrhage 
being  arrested,  the  upper  flap  is  punctured,  and  the  urethra  drawn 
through  the  face  of  the  flap,  slit  up,  and  stitched  in  situ.  The  two 
flaps,  upper  and  lower,  are  then  united  by  a  few  points  of  carbolized- 
silk  and  horsehair  suture. 

This  method  secures  a  natural  skin-covering  for  the  severed  corpora 
cavernosa,  and  prevents  the  delay  and  irritation  which  healing  bv 
granulation  entails.  A  circular  operation  was  long  ago  suggested  by 
Prof.  Miller  of  Edinburgh,  but  this  surgeon  cut  his  flap  from  below. 
If,  as  I  have  recommended,  the  flap  is  taken  from  above,  the  skin  will 
be  found  to  fall  into  position  more  readily  over  the  raw  surfaces  of  the 
corpora  cavernosa. 

Occasionally,  severer  operations  are  entirely  justifiable.  Thus^ 
where  the  penis  is  involved  as  far  back  as  the  scrotum,  the  entire 
penis  should  be  extirpated,  if  the  inguinal  glands  are  not  seriously 
involved,  and  if  the  powers  of  repair  are  satisfactory.  The  patient 
being  in  lithotomy  position,  the  scrotum  is  to  be  split  deeply  along 
the  whole  length  of  the  raphe,  and  the  corpus  spongiosum  carefully 
dissected  out.  This  step  may  be  facilitated  by  passing  a  large  sound. 
Where  the  triangular  ligament  is  exposed,  the  above  instrument  is 
removed,  and  the  corpus  spongiosum  which  has  been  dissected  out  is 


806  OPERATIONS    ON    THE    ABDOMEN. 

cut  through,  enough  being  left  to  bring  out  in  the  perineum.  By 
means  of  a  blunt  dissector,  the  crura  are  then  detached  on  either  side 
from  the  pubic  arch,  and  the  incision  being  prolonged  around  the 
penis  above,  the  suspensory  ligament  is  divided,  and  the  dorsal 
arteries  secured.  The  cut  end  of  the  corpus  spongiosum  is  now  slit 
up  and  stitched  in  the  posterior  part  of  the  scrotal  incision,  and  all 
the  rest  of  the  wound  closed  by  sutures.  Drainage  must  be  provided 
by  a  small  tube,  or  by  horsehair  drains.  Similar  operations  to  the 
above  have  been  performed  on  several  occasions,  but  the  important 
modification  of  dissecting  off  the  crura,  and  thus  ensuring  complete 
removal  of  the  cancerous  organ  and  its  capsule,  was  brought  before 
the  notice  of  English  surgeons  by  Mr.  Gould.* 

Question  of  Removing  Enlarged  Glands.  —  These  should 
always  be  extirpated  as  soon  as  it  is  probaVjle  that  the  enlargement  is 
not  merely  inflammatory.  A  week's  watching,  with  rest,  lead  lotion, 
or  the  inunction  of  mercury  oleate  (10  per  cent.),  aided  by  pressure, 
will  settle  this  point.  As  long  as  the  glands  are  involved  only  by 
growths,  hard  and  separate  from  each  other,  careful  dissection  will 
often  succeed  in  shelling  them  out,  and  thereby  add  materially  to  the 
prolongation  of  the  patient's  life.  But  where  they  contain  not  only 
secondary  deposits,  but  also  inflammatory  matter,  owing  to  ulceration 
having  set  in  at  the  seat  of  the  primary  lesion,  satisfactory  removal  of 
the  glands  is  always  a  matter  of  great  difficulty  and  often  impossible, 
owing  to  their  softness  and  tendency  to  break  down,  to  their  adhe- 
sions to  their  capsules,  and  the  matting  of  these  to  the  surrounding 
parts,  the  vascularity  of  which  is  increased,  and  tendencv  of  the  over- 
lying skin  to  become  adherent. 

In  all  such  operations  the  parts  should  be  disturbed  as  little  as 
possible,  as  erysipelas,  sloughing,  and  superficial  gangrene  are  very 
likely  to  follow  these  operations  where  planes  of  fascia  are  much  inter- 
fered with,  and  where  the  blood-supply  is  but  poor. 

I  strongly  advise  the  use  of  the  spray  in  these  cases.  Where,  owing 
to  the  presence  of  sinuses,  it  is  dispensed  with,  the  wound  should  be 
S3'ringed  from  time  to  time  during  the  operation  with  a  solution  of 
mercury  perchloride,  glycerine  and  water,  1  in  1000. 

Iodoform  and  sal  alembroth  gauze  dressings,  or  boracic-acid  lotion, 
if  erysipelas  is  feared,  will  be  found  the  best. 

*  Lancet,  May  20,  p.  821. 


RADICAL    CURE   OF    HYDROCELE.  807 


CHAPTER  XIV. 

OPERATIONS  ON  THE  SCROTUM  AND 
TESTICLE. 

RADICAL  CURE  OF  HYDROCELE.— VARICOCELE.— 
CASTRATION. 

RADICAL  CURE  OF  HYDROCELE. 

In  a  paper  written  eleven  years  ago*  I  drew  attention  to  the  uncer- 
tainty of  the  radical  cure  of  hydrocele  by  iodine  injection  as  usually 
practiced.  Thus,  out  of  forty-four  cases  treated  with  solutions  of  iodine 
and  potassium  iodide  at  Guy's  Hospital,  I  found  that  the  treatment 
failed  in  eight  cases,  and  that  in  two  it  failed  twice. 

Latterly,  I  believe  that  surgeons  have  recognized  that  the  risk  of 
recurrence  is  greater  than  that  of  excessive  inflammation,  and  stronger 
solutions  have  been  made  use  of — e.g.^  the  Edinburgh  tincture  of 
iodine — and  some  of  the  injection  has  been  allowed  to  remain.  As  it 
is  still  a  fact,  however,  that  no  method  of  cure  can  really  be  relied 
upon  as  radical  for  this  troublesome  complaint,  the  three  following 
will  be  mentioned  here — viz. : 

i.  Iodine  Injection,  ii.  and  iii.  Antiseptic  Incision  or 
Excision. 

i.  Iodine  Injection. — Supposing  the  patient  be  healthy,  not  pre- 
maturely aged,  and  amenable  to  directions,  the  surgeon  naturally 
begins  with  this  as  less  painful,  necessitating  no  open  wound  or 
dressing,  and  finally,  as  necessitating  much  less  of  the  recumbent 
position. 

I  have  already  drawn  attention  to  the  frequency  with  which  recur- 
rence is  liable  to  take  place  if  dilute  injections  are  used.  Elsewhere  I 
have  written  as  follows:  "  While  I  believe  that  the  absolute  certainty 
of  iodine  injection  has  been  over-estimated,  yet  there  is  no  doubt  that 
failure  is  too  often  courted  by  want  of  the  following  precautions  : 
(a)  The  use  of  a  too-dilute  solution ;  (6)  Not  bringing  the  solution 
in  contact  with  the  whole  of  the  sac ;  (c)  Not  withdrawing  all  the 
hydrocele  fluid ;  (rZ)  Injecting  large  hydroceles  immediately  after 
they  are  emptied;  (e)  Making  use  of  iodine  in  unsuitable  cases — viz.. 
hydroceles  with  thick  walls." 

The  method  of  injection  with  iodine  should  be  carried  out 
as  follows :  The  patient's  bowels  are  cleared  out  for  a  day  or  two 
before,  and  it  is  well  for  him  to  rest  with  his  hydrocele  well  supported 

*  Lancet,  Sept.  1,  1877:  Incision  of  Hydrocele  Antiseptically  as  a  Means  of  Radical 
Cure  rn  Certain  Cases, 


808  OPEEATIONS  ON  THE  ABDOMEN. 

for  twenty-four  hours  previous  to  the  injection.  The  fluid  is  first 
most  carefully  drawn  off  with  a  medium-sized  trocar  *  the  surgeon 
then  by  means  of  a  syringe  with  a  platinum  nozzle  accurately  fitting 
the  cannula  injects  steadily  2  to  3  oz.  of  the  tincture  of  iodine  (Edin. 
Pharm.),  taking  care  first  that  the  cannula  is  well  within  the  cavity  of 
the  tunica  vaginalis.  I  now  plug  the  cannula  with  a  snr^all  wooden 
spigot,  while  the  affected  side  of  the  scrotum  is  gently  manipulated 
and  shaken  so  as  to  bring  the  fluid  in  contact  with  all  the  interstices 
and  folds  of  the  serous  membrane.  In  five  or  ten  minutes  the  can- 
nula is  withdrawn,  as  in  most  cases  it  is  quite  safe  to  leave  in  the 
above  given  amount  of  iodine.  The  puncture  is  kept  carefully  closed 
around  the  cannula  while  this  is  taken  out,  and  then  closed  with 
iodoform  and  collodion.  A  feeling  of  heat  is  noticed  during  the  in- 
jection, sometimes  amounting  to  sickening  pain,  referred  also  to  the 
inguinal  and  lumbar  regions,  and  the  neck  of  the  bladder.  Faintness 
is  not  very  infrequent,  and  it  is  thus  well  to  tap  and  inject  the  patient 
while  he  stands  at  the  end  of  a  sofa. 

The  after-treatment  depends  on  the  amount  of  inflammation.  In 
most  cases  there  is  too  little  rather  than  too  much  of  this.  It  usually 
appears  within  two  or  three  hours,  and  if  it  be  slight  or  delayed,  the 
patient  should  be  told  to  walk  about  a  little,  and  the  sac  again  fre- 
quently manipulated.  The  patient  should  be  kept  to  his  bed  or  sofa 
for  a  day  or  two,  the  scrotum  supported,  and  plain  diet  given.  There 
should  be  no  hurry  to  employ  ice,  this  being  only  made  use  of  if  the 
swelling  promises  to  be  great.  Morphia  may  be  given  freely.  Within 
four  or  five  days  usually  the  patient  may  get  about  wearing  a  suspen- 
sory bandage.  He  should  be  prepared  for  a  return  of  the  swelling 
after  the  injection,  otherwise  he  will  be  disappointed  at  what  he  con- 
siders a  recurrence  of  his  disease.  The  swelling,  as  a  rule,  disappears 
in  three  to  four  weeks. 

In  the  case  of  a  double  hydrocele,  if  the  patient  be  healthy,  and 
not  advanced  in  years,  it  is  quite  safe  to  inject  both  sacs  at  the  same 
time,  but  in  elderl^y  or  weakly  subjects,  antiseptic  incision  will  be  the 
safest  course  if  the  patient  desires  an  operation,  otherwise  an  interval 
should  be  allowed  between  tlie  two  tap])ings. 

ii.  and  iii.  Antiseptic  Incision  and  Excision  of  the  Sac. 

— This  method  has  the  advantage  of  being  more  certain  than  that  of 
injection.  While  rendered  safe,  nowadays,  by  aseptic  treatment,  it 
has  the  disadvantage  of  being  more  severe.  Thus  an  anaesthetic  is 
required,  an  open  wound  is  present  and  several  dressings  are  needed. 
It  would  appear  especially  applicable  to  cases  (a)  of  previous  failure 
with  iodine ;    (b)  with  a  sac   very  large,  or  with  very  thick  walls ; 

*  By  some  a  solution  of  cocaine  is  now  injecteH.  I  prefer  not  to  use  this,  if  possible, 
that  no  dilution  of  the  iodine  injiection  may  occur. 


RADICAL   CURE    OF    HYDROCELE. 


809 


{(:)  where,  on  account  of  ill-health  or  premature  age,  the  risk  of  inflam- 
mation after  iodine-injection  is  especially  to  be  dreaded ;  (d)  in  cases 
of  congenital  hydrocele  (Fig.  133)  a  careful  incision  with  (Fig.  134) 
antiseptic  precautions  Avill  be  safer  than  any  other  method,  if  the 
pressure  of  a  truss  for  the  obliteration  of  the  peritoneal  communication 
cannot  be  persevered  with  ;  (e)  where  the  surgeon  is  desirous  of  ex- 
ploring the  sac  of  the  tunica  vaginalis,  as  in  cases  where  enlargement 


Fig.  133.* 


Fig.  134.* 


of  the  testis,  of  a  doubtful  nature,  coexists  with  hydrocele,  and  does 
not  yield  to  ordinary  treatment ;  (/)  where  two  hydroceles  coexist — 
e.g.,  vaginal  and  encysted  hydroceles  ;  (g)  in  some  cases  of  hydrocele 
complicated  with  hernia — e.g.,  where  the  bowel  is  irreducible,  and 
where,  especially  in  unhealthy  patients,  there  is  a  risk  of  the  inflam- 
mation set  up  by  the  iodine  extending  to  the  hernial  sac. 

Incision. — The  parts  being  shaved  and  cleansed,  an  incision,  c[uite 
2  inches  long,  is  made,  with  strict  antiseptic  precautions,  over  the 
lower  and  front  part  of  the  hydrocele,  which  is  made  tense  wdth  the 
left  hand.  This  incision  goes  down  to  the  tunica  vaginalis,  and 
the  next  opens  this  cavity  freely.  This  is  most  essential,  as,  the 
fluid  having  gushed  out,  the  long-stretched  dartos  at  once  contracts, 
closing  up  at  once  an  apparently  free  incision,  inverting  the 
edges  of  the  scrotal  skin  and  throwing  the  cavity  of  the  tunica 
vaginalis  into  a  number  of  folds.  To  facilitate  the  introduction  of 
drainage-tubes,  and  thus  the  obliteration  of  the  sac  from  the  bottom, 
the  cut  edges  of  the  tunica  vaginalis  and  the  skin  are  now  united  by 

*  Large  congenital  hydrocele  in  a  boy  of  twelve  before  and  after  antiseptic  incision. 
To  close  tlie  communication  with  the  peritoneal  cavity,  a  truss  was  worn  for  a  week 
before  the  o])eration.  In  order  to  get  at  the  neck  of  the  swelling,  to  ligature  the  pro- 
cessus fnnicularis  as  high  up  as  possible,  and  thus  prevent  any  risk  of  subsequent 
hernia,  the  incision  was  made  higher  up  than  in  incising  the  ordinary  hydrocele 
of  later  life. 


810  OPERATIONS  ON  THE  ABDOMEN. 

numerous  points  of  chromic  gut.  Unless  this  is  done  the  action  of  the 
dartos  so  puckers  together  the  folds  of  the  tunica  vaginalis  that  some 
of  these  remain  unaffected,  and  recurrence  of  the  hydrocele  may 
easily  take  place.  These  sutures  should  pass  through  any  bleeding- 
points  in  the  incision.  After  the  insertion  of  one  or  two  drainage- 
tubes,  iodoform  is  dusted  on  and  gauze  dressing  applied.  The  scrotum 
must  be  kept  well  suspended,  and  a  separate  pad  of  carbolized  tow  or 
iodoform  wool  placed  in  the  perineum  to  shut  off  the  anus.  The 
dressings  will  require  changing  once  in  three  days,  or  whenever  they 
are  loose,  and  the  drainage-tube  must  be  gradually  shortened.  In 
about  ten  days  the  granulating  spot  that  remains  may  be  dressed  with 
resin  ointment.  For  the  first  few  days  some  amount  of  orchitis  is 
usually  present,  when  this  subsides  the  patient  may  get  on  to  the 
sofa.* 

Excision. — This  method  is  indicated  in  cases  of  previous  failure, 
and  in  those  where  the  tunica  vaginalis  is  much  thickened,  or  the  seat 
of  calcareous  j^lates.  This  operation  will  rarely  be  required  if  that  of 
incision  is  carefully  carried  out,  so  as  to  secure  alteration  of  the  whole 
of  the  lining  membrane.  The  hydrocele  being  opened  freely,  the 
parietal  part  of  the  tunica  vaginalis  is  stripped  away  from  the  scrotum, 
much  as  the  sac  of  a  hernia  is  dissected  out.  It  is  cut  away  close  to 
the  testis  and  epididymis,  and  all  bleeding-points  tied  with  chromic 
gut.f  The  upper  part  of  the  wound  is  then  closed,  and  the  lower  left 
open  for  drainage. 

It  cannot  be  too  strongly  pointed  out  that  a  certain  number  of 
hydroceles  will  be  found  most  rebellious  to  attempts  at  radical  treat- 
ment. 

Thus,  in  one  case  of  mine,  recurrence  followed  after  injection  with 
undiluted  Edin.  tincture  of  iodine,  and  again  after  incision  and  drain- 
age. A  cure  took  place  after  again  incising  the  sac,  and  wiping  over 
the  interior  with  a  stick  of  nitrate  of  silver. 

Mr.  Morris  has  lately,  in  a  paper  read  before  the  Medico- Chirurgical 
Society  (Lancet,  March  3,  1888),  drawn  attention  to  this  matter.  He 
has  met  with  two  cases  in  which  recurrence  actually  took  place  after 
excision  of  the  sac. 

At  the  discussion  on  the  above  paper  the  president,  Mr.  Pollock, 
mentioned  a  case  under  his  care  which  had  been  tapped  and  injected 
twice,  and  followed  by  recurrence.     A  seton  was  then  passed  through 

*  Out  of  eleven  cases  of  antiseptic  incision  two  recurred.  One  of  these  is  n>en- 
tioned  in  the  text.  In  the  other,  a  case  of  bihiteral  hydrocele,  the  recollection  was 
small,  and  had  remained  so  in  a  stationary  condition  when  I  saw  the  patient  two 
years  afterwards. 

t  These  are  often  nnmerotis,  especially  if  a  previous  injection  with  iodine  has 
failed. 


VARICOCELE.  8il 

and  kept  in  for  three  weeks  :  this  likewise  failed.  The  sac  was  then 
incised  and  dressed  with  lint  from  the  bottom,  causing  profuse  sup- 
puration. On  allowing  the  wound  to  heal,  the  hydrocele  again 
returned,  and  it  had  since  been  treated  by  simple  tapping.  Mr. 
Treves  put  the  failures  after  incision  and  excision  as  high  as  25 
per  cent.  He  now  practiced  incision  and  swabbing  out  the  sac  with 
crude  carbolic  acid,  which  destroyed  the  endothelium  and  set  up 
su])puration. 

Causes  of  Failure  and  Trouble  after  Operations  for 
Radical  Cure. — These  ftill  mainly  into  two  classes  : 

(1.)  Recurrence. — This  is  often  due  to  the  use  of  too-diluted  in- 
jections (p.  807),  more  rarely  to  the  inveteracy  with  which  some 
hydroceles  recur  (vide  siqjra). 

(2.)  Septic  troubles. — These  should  be  practically  unknown  now- 
adays. Their  importance  formerly  is  shown  by  two  cases  given  by 
Sir  A.  Cooper  in  his  work  on  the  testis,  in  which  fatal  cellulitis 
followed  very  quickly  after  he  had  tapped  a  hydrocele. 

VARICOCELE  (Fig.  135). 

Indications. — While  palliative  treatment  will  be  sufficient  in  the 
great  majority  of  cases,  if,  at  the  same  time,  due  attention  is  paid  to 
the  general  health,  the  occupation  and  habits  of  the  patient,  and, 
where  this  is  required,  to  his  sexual  hygiene,  an  operation  will  be 
justifiable  in  the  following  cases:  (1)  Where,  in  spite  of  treatment, 
a  varicocele  steadily  increases,  and  where  it  is  accompanied  by  much 
annoyance,  distress,  and  pain;  (2)  where  the  patient  is  prevented 
from  entering  one  of  the  public  services,  or  any  active  life  in  which 
he  has  good  prospects  ;*  (3)  where  the  surgeon  has  satisfied  himself 
that  the  testis  is  undergoing  atrophy. 

The  choice  of  operation  is  a  very  large  one,  but  the  following 
will  be  found  the  simplest  and  most  efficient.  The  first  is  far  the 
safest,  and  will  replace  all  others : 

i.  Antiseptic  Excision  (Fig.  135). — This  plan  ensures  obliteration 
of  the  varicose  veins  without  risk  of  septic  cellulitis  and  secondary 
haemorrhage,  or  fatal  thrombosis  and  pyaemia.  We  owe  it  to  my 
colleague,  Mr.  Howse.f  The  bowels  having  been  cleared  out,  the 
parts  duly  shaved  and  cleansed,  the  vas  is  carefully  isolated  and 
given  to  an  assistant  to  hold.  An  incision  Ij  to  2  inches  long  is 
now  made  over  the  varicocele  thus  made  prominent,  usually  begin- 
ning about  J  inch  below  the  external  abdominal  ring.  The  overly- 
ing tissues  should  be  carefully  incised  until  the  veins  bulge  bare 

*  As  in  the  case  of  two  of  my  patients,  a  goods-guard  and  a  policeman. 
t  Guy's  Hosp.  Reports,  1887,  vol.  xxiii.  p.  468. 


812  OPERATIONS   OX   THE    ABDOMEN. 

into  the  wound.*     An  aneurism  needle,  threaded  with  chromic  gut, 
is  now  passed  at  the  upper  and  lower  angle  of  the  wound,  so  as  to 
include  a  portion  of  these  veins,  proportion- 
ate to  the  size  of  the  varicocele.     The  liga- 
tures being  tied  and  cut  short,  the  included 
bundle  of  veins  is  clipped  out  with  blunt- 
pointed  scissors.     The  remaining  veins  and 
the  vas  deferens  are  then  carefully  replaced. 
Every  care  should  be  taken  to  disturb  the  parts 
as  little  as  possible,  especially  the  connective 
tissue  about  the  vas,  as  in  this  run  a  num- 
ber of  small  veins  which,  if  undisturbed,  are 
quite  sufficient  to  carry  on  the  circulation.! 
The  testis  should  also  be  kept  down  by  the  finger  of  the  assistant 
who  has  charge  of  the  vas  deferens,  as  it  has  a  tendency  to  protrude 
when  the  vas  is  pulled  upon.     A  little  iodoform  is  then  dusted  on, 
a  horsehair  drain  inserted,  the  wound  united   with  carbolized  silk 
and  horsehair  sutures,  and  aseptic  gauze  dressings  applied.     Strict 
antiseptic  precautions  are  required  throughout.     The  wound  should 
be  dressed  on  the  fourth  day,  to  remove  the  drain,  and  again  about 
four   days   later,  to  remove  the   sutures.     The   recumbent  position 
should  be  maintained  for  three  weeks. 

Some  of  the  scrotal  skin  may  now  be  removed,  if  very  redundant, 
and  any  enlarged  scrotal  veins  tied ;  but  neither  of  these  steps  are  of 
the  least  service  without  ligature  of  the  varicocele  itself. 

I  have  not  described  any  other  operation  chiefly  because  they  in- 
volve suppuration,  and,  though  subcutaneous,  are  operations  in  the 
dark.  An  account  of  the  operations,  practiced  with  wire  and  pins,  of 
Mr.  Erichsen  and  Mr.  Curling,  will  be  found  in  my  article  above 
quoted  ;  they  are  briefly  alluded  to  below. 

ii.  Mr.  Erichsen'st  Modification  of  the  Operation  of  Vidal 
de  Cassis. — The  vas  deferens,  readily  distinguished  by  its  cord-like 
feel,  is  first  separated  from  the  veins  and  entrusted  to  an  assistant  to 
hold  :  an  incision  about  2  inch  long  is  then  made  in  the  front  and 
back  of  the  scrotum,  a  needle,  so  threaded  with  silver  wire  that  the 
wire  will  follow  without  dragging,  is  then  passed  between  the  vas  and 
the  veins,  and  brought  out  behind  ;  the  needle  is  then  re-entered  and 
carried  out  in  front,  but  this  time  is  passed  between  the  veins  and  the 
skin,  thus  including  the  veins  in  a  loop  of  wire,  without  implicating 

*  Care  must  be  taken  to  expose  the  veins  thoroughly,  otherwise  difficulty  will  be 
experienced  in  passing  the  ligatures. 

t  See  Fig  113,  p.  566,  of  my  article  un  The  Diseases  of  the  Male  Organs,  Syst.  of 
Surg.,  vol.  iii. 

X  Surgery,  vol.  ii.  p.  960. 


VARICOCELE.  813 

the  scrotum.  The  loop  is  then  tightl}^  twisted  so  as  to  constrict  the 
enclosed  vessels.  From  day  to  day  the  wire  is  tightened  up  afresh, 
until  it  has  completely  made  its  way  through  the  veins  by  ulceration, 
a  process  Avhich  takes  about  seven  or  ten  days.  Meanwhile  there  is 
much  plastic  matter  thrown  out  around  the  veins,  which  finally  con- 
tracts and  obliterates  them. 

iii.  The  following  is  the  operation  by  ligature  and  pins  of  Mr. 
Curling:*  The  vas  being  separated  from  the  veins  a  straight  pin  is 
passed  between  the  two,  about  2  inches  above  the  testicle,  and  about 
f  inch  below  this  point  another  pin  is  passed.  A  piece  of  card  is 
then  applied  over  the  pins  so  as  to  guard  the  skin  from  ulceration, 
and  a  stout  silk  ligature  applied  in  a  figure-of-eight  form.  The  sharp 
ends  of  the  pins  are  then  nipped  off,  and  the  operation  is  completed 
by  freely  dividing  the  veins  subcutaneously  with  a  narrow  tenotome 
half-way  between  the  jjins.  On  the  sixth  day  the  pins  are  removed. 
A  few  days  later  the  patient  can  usually  get  up  wearing  a  suspensory 
bandage. 

Diflaculties  and  Causes  of  Trouble  in  the  Radical  Cure 
of  Varicocele. — These  fiill  into  two  classes. 

1.  Sepsis  and  its  Results. — The  risk  of  these  is  always  present  with 
the  old  subcutaneous  operation.  A  good  instance  of  these  has  been 
recorded  by  Mr.  H.  Lee.f  Here  erysipelas,  repeated  haemorrhages, 
sloughing  of  the  skin  of  the  scrotum  and  penis,  and  multiple  ab- 
scesses, followed  on  Mr.  Lee's  operation  performed  by  himself.  It  is 
certain  that  others  have  not  been  so  candid.  As  Mr.  Lee  mentions 
local  abscess,  destruction  of  a  small  portion  of  skin,  and  on  two 
or  three  other  occasions,  arterial  haemorrhage,  controlled  by  intro- 
ducing a  third  pin,  as  having  happened  with  his  experienced  hands, 
surgeons  will  prefer  the  open  and  aseptic  operation.  The  small 
wound  made  here  usually  requires  only  three  dressings.  In  both 
cases  a  suspensory  bandage  will  be  required  till  all  trace  of  the 
inflammatory  thickening  has  disappeared  ;  this  will  take  six  to  eight 
weeks. 

2.  Inclusion  of  too  many  Veins. — That  this  is  a  real  danger  is 
shown  by  a  case  of  mine  which  I  have  published. J  The  patient  here 
had  a  double  varicocele,  that  on  the  left  side  being  truly  enormous. 
This  was  my  third  case,  and  was  operated  on  with  the  same  precau- 
tions as  to  the  vas  and  asepsis  given  at  p.  811.  Owing  to  the  huge 
size  of  the  varicocele  three  bundles  of  veins  were  removed,  and  even 
then  a  large  number  appeared  to  be  left,  the  varicocele  being  now  a 
quarter  of  its  former  size.  The  case  did  well  up  to  the  eighth  day, 
when  the  wound  opened  and  the  lower  half  of  the  testis,  evidently 

*  7e.s/w,  p.  513,  Fig.  44. 

t  Clin.  Soc.  Trans.,  vol  i.  p.  73. 

X  Syst.  of  Surg.,  vol.  iii.  p.  571. 


814  OPERATIONS  ON  THE  ABDOMEN. 

gangrenous,  presented  itself.  This  was  cut  away  after  the  application 
of  a  chromic-gut  ligature.  Though,  at  the  close  of  the  operation,  it 
did  not  appear  that  too  many  veins  had  been  removed,  such  must 
have  been  the  case. 

Since  this  I  have  had  seven  cases  which  have  all  done  excellently. 

CASTRATION  (Fig.  136). 
Indications. 

I.  Growths  of  the  testicle. 

1.  Sarcomata. — The  following  practical  points  deserve  allusion. 
The  varieties  of  round,  spindle,  and  mixed-cell  sarcoma  are  all  met 
with  here,  together  with  the  sub-variety  of  the  first  called  lympho- 
sarcoma or  lymphadenoma,  from  the  likeness  of  its  cells  to  those  of 
lymphatic  tissue.  Of  the  above,  the  spindle-cell  sarcoma  is  the  one 
most  frequently  associated  with  other  structures  of  the  connective- 
tissue  group — viz.,  cartilage,  myomatous,  adipose,  and  even  muscular 
tissue.  While  pure  forms  of  sarcoma  are  not  often  met  with  in  the 
testicle,  the  round-cell  variety  is  the  one  most  often  met  Avith  in  the 
unmixed  form,  thus  accounting  for  its  far  more  rapid  growth,  more 
marked  tendency  to  secondary  deposits,  and  thus  its  shorter  duration. 
Cystic  Sarcovia. — This  is  occasionally  spoken  of  as  a  distinct  disease; 
it  means,  I  believe,  only  an  early  stage  of  sarcomatous  disease,  a 
stage  of  varyi]ig  duration,  but  one  that  is  very  liable  to  be  followed 
by  rapid  increase  locally,  and  probably  by  secondary  deposits  else- 
where. The  combination  of  cysts  and  sarcoma  is  very  common,  and 
is  met  with  in  two  quite  distinct  forms  :  (a)  Simple  cysts,  with  a  fibro- 
cellular  wall  and  a  lining  of  tessellated  epithelium,  and  contents 
serous,  viscid,  or  mixed  with  blood.  This  is  the  variety  which  is 
often  called  "  cystic  disease,"  and  which  is  looked  upon  as  innocent. 
While  I  grant  that  this  form  may  remain  long  quiescent,  I  think  it 
should  be  looked  upon  as  an  early  stage  of  sarcoma,  though  the  date 
of  its  taking  on  dangerous  growth  is  quite  uncertain,  and  may  be 
long  deferred.  (6)  Proliferous  cysts.  Here  the  cysts  contain  sprout- 
ing, foliaceous  or  papillomatous  growths,  myxo-sarcomatous  in  struc- 
ture, while  the  inter-cystic  disease  is  also  frequently'  myxoniatous  or 
myxo-sarcomatous. 

2.  Enchondroma. — I  have  elsewhere*  expressed  my  belief  that  this 
is  merely  a  variety  of  sarcoma,  and  being  never  really  innocent, 
should  be  treated  accordingly.  Most  frequently  cartilage  occurs  in 
the  testicle  in  combination  with  sarcomatous  and  cystic  disease. 
Another,  and,  at  first  sight,  quite  a  distinct  form,  is  that  in  which  the 
cartilage  occurs  in  hyaline  masses,  and  apparently  without  cysts  and 

*  Syst.  of  Surg.,  vol.  iii.  p.  540. 


CASTRATION.  815 

sarcomatous  material.  I  believe  that,  clinically,  it  is  extremely 
doubtful  whether  these  apparently  simple  enchonclromata  may  not, 
at  any  time,  become  sarcomatous.  No  doubt  we  occasionally  meet 
with  cases  of  enchondromata  of  the  testicle  which  have  been  growing 
slowly  for  perhaps  three  or  four  years,  and  in  which  there  may  be  no 
recurrence  during  the  four  or  five  years  in  which  the  patient  remains 
under  observation,  perhaps  for  the  rest  of  his  lifetime.  But  when  the 
close  relations  of  cartilage  to  the  other  tissues  of  the  connective  type 
are  considered,  and  when  it  is  remembered  how  narrow  is  the  border 
line  between  these  tissues  and  sarcomata,  especially  when,  submitted 
to  irritation  or  inflammation,  the  former  tend  to  recur  to  their  embry- 
onic forms,  it  may  well  be  doubted  if  an  enchondroma  of  the  testicle 
ever  really  deserves  the  term  "  innocent." 

3.  Cystic  Disease. — This  has  been  already  referred  to,  p.  814. 

4.  Fibroma  or  Fibro-viyoma . — These  are  so  rare  as  to  need  no  further 
remark. 

5.  Dermoid  Cysts. — These  are  also  extremely  rare. 

6.  Carcinoma. — The  encephaloid,  a  soft  variety,  is  not  unfrequently 
met  with  in  the  testicle.  Of  scirrhus  a  few  authenticated  cases  are  on 
record.  Encephaloid  carcinoma  may  make  its  appearance  at  any 
time  of  life  but  is  most  common  in  the  first  half  of  adult  life — i.e., 
from  twenty  to  forty.  It  is  rare  after  sixty,  and  practically  unknown 
in  infancy.  It  is  usually  rapid  in  all  its  stages,  its  average  duration 
being  from  eighteen  months  to  two  years. 

Diagnosis  of  Malignant  Disease  of  the  Testis. — As  the  records 
of  surgery  contain  many  instances  of  mistakes  under  able  hands— 
hematoceles  removed  for  malignant  disease,  and  malignant  testes 
opened  for  hsematocele,  a  few^  hints  may  not  be  out  of  place  here  on 
the  subject  of  castration.  Sarcomata  and  carcinomata  Avill  betaken 
together.  In  the  early  stage  these  are  liable  to  be  confused  with  chronic 
inflammatory  enlargements  of  the  testicle,  owing  to  their  often  possess- 
ing, at  this  period,  an  oval  shape,  a  smooth  outline,  and  a  certain  degree 
of  hardness.  A  little  later  the  indistinct  fluctuation  which  accompa- 
nies the  softening  of  the  growth,  coupled  perhaps  with  the  presence 
of  fluid  in  the  tunica  vaginalis,  causes  a  deceptive  resemblance  to  an 
old  hydrocele  and  hsematocele,  with  thickened  walls,  especially  where 
transjDarency  is  entirely  wanting,  and  the  tumor  feels  heavy  and  fluc- 
tuates obscurely. 

The  following  are  amongst  the  points  on  which  most  reliance 
may  be  placed — (1)  Continuously  progressing  solid  enlargements 
without  inflammation.  (2)  Unequal  consistence  of  the  swelling  at 
diflferent  parts.  (3)  Entire  absence  of  translucency.  (4)  Tendency 
of  the  scrotal  veins  to  become  enlarged,  and  of  the  scrotal  tissues  to 
become  adherent.  (5)  Increasing  aches  or  j^ainfulness.  (6)  In  doubtful 


816  OPERATIONS  ON  THE  ABDOMEN. 

cases  additional  information  should  be  at  once  sought  for  by  an  anti- 
septic tapping  or  exploratory  incision.  The  latter  is  preferable,  as  it 
gives  more  certain  information,  and  is  the  best  treatment  in  those 
cases  of  htematocele  which  are  liable  to  be  mistaken  for  malignant 
disease.  Puncture  of  a  malignant  growth  usually  gives  vent  to  blood- 
stained fluid,  which  is  not  large  in  amount,  or  to  sero-mucous  fluid, 
which  is  not  blood-stained.  On  puncture  of  a  hfematocele  there  usu- 
ally escapes  either  grumous  altered  blood  or  fluid  blood,  which  flows 
for  some  time,  producing  a  distinct  alteration  in  the  size  of  the  swell- 
ing. (7)  Enlargement  of  the  cord,  and  a  fortiori,  that  of  the  lumbar 
glands. 

Results  of  Castration  in  Malignant  Disease.— These  may  be 
considered  from  three  points  of  view — (a)  The  danger  of  the  operation. 
{b)  The  chances  of  cure,  (c)  The  amount  of  relief  which  it  gives  when 
a  cure  is  not  afforded. 

(a)  The  Danger  of  the  Operation. — Tfiis  is  extremely  small.  The  wound 
heals  most  rapidly  if  aseptic  precautions  are  taken,  and  if  no  risk  has 
to  be  run  (as  is  very  seldom  the  case)  of  encroaching  on  the  peritoneum 
by  slitting  up  the  inguinal  canal,  (b)  The  Chances  of  Cure. — Perma- 
nent successes  are  very  rare.  This  is  mainly  owing  to  the  time  lost  in 
the  early  stage  in  administration  of  drugs  and  in  strapping,  and  to  the 
unwillingness  of  the  patient  to  submit  to  castration.  A  few  cases  are 
on  record  which  have  been  sufficiently  Avatched  to  show  how  lasting 
may  be  the  cure.  Thus,  Mr.  Curling*  mentions  four  cases  in  which, 
after  removal  of  the  testis  for  soft  malignant  disease  (whether  sarcoma 
or  carcinoma,  is  not  stated),  life  was  prolonged  for  fifteen,  five,  nine, 
and  twelve  years,  the  patients  in  the  last  three  cases  being  still  alive 
when  the  last  report  was  received,  (c)  The  Amount  of  Relief. — Even 
when  the  cure  is  not  permanent,  castration  may  prolong  a  useful  life, 
the  patient,  rid  of  a  wearisome  encumbrance,  is  made  more  comfortable, 
and,  towards  the  close,  death  from  internal  deposits  is  not  accompanied 
with  the  same  distress,  both  to  the  patient  and  those  around  him,  as 
when  the  disease  is  situated  externally. 

Contra-Indications. — Castration  should  not  be  performed  when 
the  cord  is  extensively  involved  ;  when  masses  can  be  felt  deep  seated 
in  the  iliac  fossa  and  lumbar  region  ;  when  there  is  any  evidence  that 
the  liver  or  lungs  are  involved  ;  or  when  the  jaundiced,  sallow  tint,  and 
rapid  emaciation  point  to  the  disease  having  become  general.  In 
cases  at  all  advanced,  though  the  patient  might  be  rid  of  an  encum- 
brance, the  operation  would  be  very  liable  to  be  followed  by  a  low 
form  of  peritonitis,  or,  before  the  wound  was  healed,  swelling  would 


*  Dls.  of  the  Testis,  pp.  341,  342. 


CASTRATIOX.  817 

probably  appear  in  the  inguinal  region,  and  a  protrusion  of  the  growth 
take  place  from  the  upper  extremity  of  the  wound. 

II.  Tubercular  Testicle. — I  am  of  opinion  that  castration  should  be 
performed  much  earlier  in  this  disease  than  is  usually  the  practice. 
Natural  cures  are  so  few,  dissemination  is  so  frequent  and  so  grave, 
whether  to  bladder  and  kidneys,  vesiculse  seminales,  or  prostate,  or  to 
the  lungs,*  while,  on  the  other  hand,  castration  is,  nowadays,  so  safe 
an  operation,  that  it  should  not  be  deferred. 

Indications. — 1.  Failure  of  previous  treatment.  2.  Hernia  testis. 
3.  Persistence  of  a  discharging  sinus  affecting  the  general  health,  in- 
terfering with  the  out-door  exercise  so  necessary  to  these  cases.f  4. 
Commencing  enlargement  of  cord,  slight  thickening  of  vesiculae  semi- 
nales.    Nodules  in  the  prostate  still  hard  and  craggy. J 

III.  Syphilitic  Testi'^. — Here,  owing  to  the  specifics  which  we  possess, 
castration  is  much  more  rarely  called  for.  The  indications  can  readily 
be  judged  of  from  those  above  given. 

IV.  Old  Heematocele. 

Indications. — Failure  of  previous  treatment,  especially  in  n  man  of 
middle  life  whose  activit}^ — e.g.,  in  riding— is  much  interfered  with.§ 

V.  Retained  Testis. 

Indications.- — 1.  When  such  a  testis  is  the  seat  of  malignant  disease. 
2.  When  it  seriously  cripples  the  patient  by  the  recurrent  attacks  of 
inflammation  associated  with  it.  3.  When  a  coexisting  hernia  cannot 
be  kept  up  by  a  truss,  owing  to  the  presence  of  the  testis. 

Much  rarer  indications] |  are:  VI.  Insanity,  chronic  ejyilej^sy,  etc.,  kept 
up  by  onanism.  VII.  Injury.  VIII.  The  radical  cure  of  hernia — i.e., 
when  the  operation  cannot  be  completed  without  removal  of  the  testis, 
owing  to  the  firm  adhesions  of  the  sac  to  the  cord,  especially  when  this 
occurs  in  a  patient  approaching  middle  age.  It  is  always  well,  here, 
to  obtain  leave  for  castration. 

*  Mr.  Bennett,  in  a  paper  bronght  before  tlie  Medico-Chiriirgical  Society  {Brit.  Med. 
Journ.,  January  28,  1888),  sliowed  that  in  each  of  his  five  cases  the  spinal  cord  became 
affected  before  any  of  the  parts  in  the  immediate  neighborhood  of  the  testis,  and  that 
this  spinal  disease  was  markedly  insidious.  I  should  have  thought  the  above  coinci- 
dence of  spinal  disease  with  tubercular  testis  a  rare  one. 

t  Early  phthisis  should  not  interfere  with  removal  of  a  tubercular  testis,  which 
resists  treatment  and  prevents  the  patient  getting  open-air  exercise,  and  weakens  his 
health  by  discharge.  Owing  to  the  condition  of  the  lungs,  chloroform  should  be  here 
given,  instead  of  ether. 

X  Tubercular  disease  of  the  prostate  is  a  source,  usually,  of  such  extreme  misery, 
that  any  existing  cause  in  the  testis  should  be  removed  very  early. 

§  The  frequency  with  wliich  malignant  disease  follows  on  repeated  injury  and  irri- 
tation of  the  testicle  is  well  known  (Rindfleisch,  Path.  Hist.,  vol.  ii.  p.  197). 

II  On  these  subjects  I  rnay  refer  my  readers  to  my  article  already  quoted  from  Syst. 
of  Siirg.,  vol.  iii. 

52 


818 


OPERATIONS  ON  THE  ABDOMEN. 


Operation  (Fig.  136). — The  absence  of  any  hernia  on  the  side 
operated  on  having  been  ascertained,  and  the  parts  duly  shaved  and 
cleansed,  the  surgeon  protrudes  the  testicle  with  his  left  hand  so  as  to 
make  the  overlying  tissues  tense,  and  divides  them  from  the  external 
abdominal  ring  to  the  bottom  of  the  scrotum  so  as  to  ensure  free  and 
easy  drainage.     In  cases  where  the  skin  is  involved  by  a  growth,  or 

Fig.  136. 


ulcerated  by  a  hernia  testis,  two  elliptical  incisions  should  be  made, 
well  wide  of  the  disease,  and  meeting  above  and  below.  The  first  in- 
cision having  exposed  the  cord  above,  this  is  defined,  and  the  scrotal 
tunics  are  quickly  shelled  off  with  the  right  hand,  while  the  testis  is 
still  further  protruded  with  the  left.*  The  spermatic  cord  is  now  iso- 
lated as  high  as  may  be  needful,  the  inguinal  canal  being  carefully 
opened  upon  a  director,  if  this  is  necessary  to  get  above  the  disease. 
An  aneurism  needle,  threaded  with  a  double  ligature  of  carbolized  silk 
or  stout  chromic  gut,  is  passed  through  the  cord,  the  loop  of  the  liga- 
ture cut,  the  needle  withdrawn,  and,  the  cord  having  been  thus  tied 
in  two  halves,  the  ends  of  one  ligature  are  cut  short,  while  those  of  the 
others  are  tied  round  the  whole  end  to  ensure  that  no  vessel  escapes. 
The  ends  of  this  also  are  then  cut  short.  The  ligatures  being  thus  im- 
bedded in  the  cord  substance,  there  is  no  risk  of  their  slipping,  and  if 
they  be  tied  as  tightly  as  possible  (by  looping  the  ligatures  round  two 
pairs  of  scissors  or  forceps),  there  is  no  risk  of  causing  the  patient  any 

*  There  is  often  an  adhesion  below  and  between  the  testis  and  the  fundus  of  tlie 
scrotum  (Fig.  136).  This  represents,  according  to  some,  tiie  remains  of  the  mesorchium. 


FISTULA.  819 

suffering.  Other  methods  consist  in  securing  the  vessels  alone,  singly, 
by  torsion,  or  by  chromic  gut,  or  by  fixing  the  cord  in  the  upper  angle 
of  the  wound  with  a  clamp.  The  mode  of  ligature  above  given  is 
much  more  speedy  and  also,  I  think,  efficient.  Securing  each  vessel  is 
tedious,  as  it  is  needful  to  make  sure  of  every  one,  even  when  they  are 
not  enlarged,  a  condition  not  infrequent  in  growths.  If  any  of  the 
arteries  are  left  unsecured,  dangerous  bleeding,  when  the  cord  retracts 
upwards,  calling  for  laying  open  of  the  canal,  with  the  risk  of  cellulitis, 
is  very  probable. 

The  cord,  being  secured,  is  severed  at  least  i  inch  above  the  disease, 
and  the  mass  removed.  The  wound  is  then  examined  in  the  c.ise  of 
a  soft,  rapid  growtli,  and  where  a  tuV^ercular  testis  has  threatened  to 
fungate,  any  suspicious  skin  must  be  clipped  away  or  a  sharp  spoon 
freely  used. 

A  few  scrotal  vessels,  notably  one  in  the  septum,  may  require  se- 
curing. The  wound  is  then  closed  with  carbolized  silk  and  horsehair, 
pains  being  taken  to  meet  the  tendency  of  the  scrotal  edges  to  invert. 

Drainage  should  be  carefully  provided,  and  every  precaution  taken 
during  and  after  the  operation  (including  the  spray,  or  irrigation  with 
hydi'.  perch,  and  glycerine)  to  promote  rapid  healing,  especially  in 
hos])ital  practice.  Patients  who  have  to  submit  to  castration  are  often 
reduced  in  health,  and  are  thus  liable  to  erysipelas,  and  in  septic  cases 
a  low  form  of  peritonitis  is  very  likely  to  follow,  especially  if  the  canal 
has  been  opened  up,  while  septic  thrombosis  is  very  likely  to  follow 
on  a  wound  made  on  a  region  so  abounding  in  lymphatics  and  loose 
cellular  tissue. 


CHAPTER  XV. 
OPERATIONS  ON  THE  ANUS  AND  RECTUM. 

FISTULA  —  HEMORRHOIDS  -  FISSURE— PROLAPSUS  - 
EXCISION  OF  THE  RECTUM— IMPERFORATE  ANUS— 
ATRESIA  ANI-IMPERFECTLY  DEVELOPED  RECTUM. 

FISTULA. 

Varieties. — As  these  have  a  very  practical  bearing  upon  the  oper- 
ation they  must  be  alluded  to  here. 

i.  Complete. 

ii.  Blind  External. — Here  an  external  opening  only  exists,  though  in 
a  considerable  number  of  cases  the  internal  opening  is  overlooked. 

iii.  Blind  Internal. — An  opening  through  the  mucous  membrane  is 


820  OPERATIONS  ON  THE  ABDOMEN. 

here  the  only  one*  This  is  the  rarest,  but  an  important  variety,  as, 
if  overlooked,  it  is  certain  to  be  troublesome. 

Situation  of  Openings. — Both  of  these  are  usually  witliin  an  inch,  more 
often  2  inch,  of  the  anus.  The  internal  one  may  be  detected  as  a  slight 
depression  or  papilla  by  the  finger,  or  by  the  speculum,  or,  in  obscurer 
cases,  by  Mr.  Lund's  method.f 

Horseshoe  Fistulx. — Here  an  external  opening  on  either  side  commu- 
nicates with  a  single  internal  one,  often  at  the  back.  This  is  an  un- 
common but  an  important  variety,  for  if  it  is  found  necessary  to  cut 
through  the  sphincter  ani  at  both  sides,  some  loss  of  power  is  very  likely 
to  ensue.  This  risk  should  be  explained  to  tbe  patient,  and  the  shal- 
lower fistula  should  be  scraped,  while  the  deeper  is  freely  incised.  If 
it  is  necessary  to  cut  the  sphincter  on  both  sides,  the  knife  should  be 
employed  on  two  distinct  occasions,  time  being  given  for  the  first  to 
heal.J ' 

Multiple  Fistulx. — This  condition  should  always  cause  a  suspicion 
of  stricture,  or  extensive  ulceration — e.g.,  dysenteric,  etc. 

Fistula  iclth  Phthisis. — Where  a  fistula  presents  an  external  opening 
with  undermined,  livid  edges,  where  the  tubera  ischii  stand  out 
prominently  from  emaciated  nates,  and  where  the  hair  of  the  part  is 
long  and  curled,  phthisis  is  always  to  be  suspected,  even  if  no  history 
of  cough  or  haemoptysis  be  given. 

Question  of  Operating  on  Phthisical  Patients. — While  each  case  must 
be  decided  by  itself,  the  following  remarks  may  be  useful : 

Where  the  phthisis  is  advanced,  the  cough  incessant,  the  fistula 
multiple  or  branched,  an  operation  is  out  of  the  question.  On  the 
other  hand,  where  the  physical  signs  are  little  marked,  night  sweats 
slight  or  absent,  where  the  fistula  interferes  with  the  patient  taking 
the  all-essential  exercise,  where  the  power  of  rejDair  is  good,  an  ope- 
ration is  indicated. 

In  cases  intermediate  between  the  above  each  one  must  be  decided 
upon  its  own  merits. 

Before  operating,  the  surgeon  should  remember  that  repair  is  here 
often  sluggish,  the  mental  condition  much  depressed.  He  should  do 
all  he  can  to  improve  the  general  condition  before  and  after  the  ope- 

*  A  discolored  dot  or  i)atch  of  skin  sometimes  marks  tlie  place  wliere  an  external 
opening  may  occur.  Mr.  Lnnd  {Hmit.  Jjcct.,  p.  88)  relates  a  case  in  which  a  very 
chronic  and  slowly  advancing  blind  internal  fistnla  had  excited,  by  its  exlieine  end, 
just  enough  inflammatory  tliickening  of  the  skin  as  to  imitate  a  keloid  growth,  for 
which  it  was  at  first  mistaken. 

t  See  foot- note,  p.  593. 

X  Mr.  Cripps  (Dis.  of  Rectum  and  Anus,  p.  165)  shows  that  if,  in  women,  the 
sphincter  is  cut  through  anteriorly  where  it  decussates  with  the  sphincter  vaginae,  incon- 
tinence of  fseces  is  very  likely  to  take  place. 


FISTULA.  821 

ration.  And  if  this  can  be  performed  in  sunn}'^  weather,  or,  better 
still,  at  the  sea-side,  so  that  the  patient  can  soon  have  fresh  air  in  the 
recumbent  position,  so  much  the  better. 

Operation. — For  a  few  days  before  the  operation  the  diet  should 
be  restricted,  and  the  bowels  emptied  by  aperients.  The  hour  of  the 
operation  should  be  so  arranged  as  to  give  time  for  the  enema  which 
should  be  given  to  come  away.  The  patient  being  under  an  anes- 
thetic, and  either  on  his  side  with  the  knees  well  flexed,  or  in  lithot- 
omy position,  the  surgeon  introduces  lightly  a  fine  Brodie's  probe. 
In  the  case  of  a  complete  fistula,  the  internal  opening  being  hit  off 
(p.  820),  the  point  of  the  probe  is  felt  for  by  the  finger  and  hooked 
out  of  the  anus.  If,  after  careful  examination,  the  surgeon  is  satisfied 
that  no  internal  opening  exists,  he  makes  one  by  finding  the  exact 
spot  at  which  the  coats  of  the  bowel  are  most  thinned,  thrusting  the 
point  of  the  probe  through  here. 

In  the  case  of  a  blind  internal  fistula  the  internal  opening  must  be 
found  with  a  speculum  and  the  probe,  curved,  passed  from  this  so  as 
to  project  beneath  the  skin.  In  every  case  the  whole  length  of  the 
sinus  between  skin  and  bowel  must  be  completely  laid  open.  When 
this  has  been  done,  very  careful  examination  is  made  for  other  sinuses 
by  the  introduction  of  the  probe,  and  by  pressure  with  the  finger, 
which  squeezes  out  any  discharges,  and  feels  for  indurated  tracks. 
Wherever  these  run,  they  must,  if  possible,  be  laid  open.  I  have 
already  (p.  820)  alluded  to  the  question  of  dividing  the  sphincter  in 
two  places.  If  any  sinus  seems  to  run  dangerously  high,  hteraor- 
rhage  may  be  avoided  by  dividing  it  with  a  small  ecraseur,  or,  more 
gradually,  by  the  elastic  ligature.  Every  attempt,  however,  should 
be  made  Avith  the  aid  of  a  good  light  and  forcible  dilatation  of  the 
sphincter  to  lay  open  every  sinus  with  bistoury  or  scissors,  extra  care 
oeing  taken,  the  higher  the  incision  has  to  be  carried,  to  arrest  all 
bleeding  with  carbolized  silk  ligatures. 

While  the  sinuses  are  being  followed  up,  any  old  gristly  tissue  must 
be  completely  divided,  all  pyogenic  or  granulation  tissue  entirely 
scraped  out,  and  all  ill-nourished  flaps  and  tags  of  undermined  skin 
cut  away. 

If  any  troublesome  piles  coexist  they  should  be  tied  and  cut  away 
at  the  same  time,  p.  823. 

As  a  dressing  I  prefer  a  little  twisted  cotton  wool  dusted  with  iodo- 
form, as  I  find  this  adapts  itself  more  easily  to  the  different  wounds. 
Less  and  less  should  be  applied,  daily,  as  granulations  become  estab- 
lished. Daily  plugging  with  strips  of  lint  out  of  carbolic  oil  only 
makes  the  wounds  irritable  and  oedematous.  After  the  first  week 
little  more  is  needed  than  daily  cleansing  of  the  wound  with  a  camel's- 
hair  brush,  or  a  dossil  of  cotton  wool  on  a  Playfair's  probe.     If  the 


822  OPERATIONS  ON  THE  ABDOMEN. 

edges  of  the  wound  close  too  soon  they  should  be  separated  with  a 
probe  from  time  to  time,  or  any  redundancy  may  be  painted  with 
cocaine  and  snipped  away* 

Finally,  no  operation  better  exemplifies  the  truth  of  Mr.  Curling's 
saying,  that  the  surgeon  should  be  here  his  own  dresser. 

HEMORRHOIDS. 
Indications. 

1.  Continuance  of  hemorrhage  or  discharge,  and  persistent  liability 
to  descent  of  piles  in  spite  of  judicious  treatment. 

2.  Absence  of  albuminuria,  diabetes,  hepatic  (probably,  cardiac) 
disease. 

3.  Amenability  on  the  part  of  the  patient. f 
Operations. 

Ligature.  —  Cautery.  —  Crushing.  —  Acid.  —  Whitehead's 
Operation. 

i.  Ligature. — I  have  placed  this  first,  from  a  strong  belief  that,  if 
properly  used,  it  is,  on  the  whole,  the  best  method  and  the  one  most 
generally  applicable.  Here,  as  elsewhere,  that  surgeon  will  have  the 
best  results  who  has  thoroughly  familiarized  himself  with  the  details 
of  one  operation.  The  following  appears  to  me  to  be  a  fair  way  of 
putting  the  merits  of  ligature  and  the  other  operations  : 

1.  The  ligature  is  more  generally  suited  to  all  cases.  Thus  it  can 
be  more  easily  applied  to  piles  high  up  than  can  the  cautery,  2.  No 
special  instruments  are  needed.  3.  A  ligature  applied  is  done  once 
for  all ;  the  cautery  may  have  to  be  reapplied  more  that  once  if  bleed- 
ing follows  when  the  clamp  is  unscrewed.  4.  The  ligature  is  free 
from  the  objections  to  the  cautery  in  private  practice. 

On  the  other  hand,  the  recovery  after  the  cautery  is  usually  a  little 
quicker,  as  no  ligatures  have  to  be  detached.  If,  however,  the  liga- 
tures are  properly  applied,  there  is,  practically,  very  little  difference. 
As  to  the  risk  of  secondary  haemorrhage,  most  surgeons  will  feel  more 
absolute  security  after  using  the  ligature,  aided  by  the  use  of  iodo- 
form, etc. 

*  Anotlier  excellent  dressing,  later  on,  is  dilute  nitric  acid  lotion,  10  minims  to  1 
oz.     This  needs  changing  every  four  or  six  hoars. 

t  In  Mr.  Cripps's  words  {loc.  supra  cit.,  p.  99) :  "  The  smallness  of  the  risk  should 
not  lull  the  surgeon  into  a  sense  of  absolute  security,  and  he  should  sparie  no  effort  in 

ascertaining  the  general  constitutional  condition  of  his  patients The  amount  of 

risk,  slight  as  it  is,  should  be  clearly  laid  before  the  patient  or  his  friends.  If  a  man 
is  to  have  some  grave  operation  performed,  sucli  as  the  removal  of  a  cancer  or  the 
amputation  of  a  limb,  both  he  and  his  friends  are  well  aware  of  the  risk  involved,  and 
are  accordingly  pre[)ared.  It  is,  therefore,  in  the  smaller  operations,  regarded  by  the 
surgeon  and  public  as  free  fioni  danger,  that  a  fatality,  when  it  does  occur,  becomes 
so  tragic  from  being  unexpected." 


HEMORRHOIDS.  8  "2  3 

Operation. — The  preparatory  treatment  is  that  given  at  p.  821, 
The  patient  being  on  his  left  side,  or  in  the  lithotomy  position,  the 
anus  must  he  dilated,  if  sitting  for  a  quarter  of  an  hour  over  hot 
water  has  not  brought  down  tlie  piles  sufficiently.  This  may  be  done 
by  introducing,  and  then  separating  laterally,  the  two  thumbs,  the 
pressure  being  steadily  maintained  so  as  not  to  rupture  the  mucous 
membrane;  after  a  few  minutes  a  sensation  of  giving  rather  than  of 
tearing  is  perceived,  or  the  whole  hand  ma}'  be  introduced  in  the  form 
of  a  cone.  Another  method  is  to  introduce  a  large  bi-  or  multi- 
valve  vaginal  speculum,  and  to  withdraw  this  expanded.*  When  the 
sphincters  are  thoroughly  dilated  the  largest  pile  is  drawn  down  with 
a  vulsellum  or  tenaculum  forceps,  and  the  surgeon,  with  blunt-pointed 
scissors,  curved  on  the  flat,  cuts  a  groove  around  the  lower  two-thirds 
of  the  pile.  In  the  lower  piles  this  groove  should  commence  in  the 
sulcus,  which  marks  the  junction  of  skin  and  mucous  membrane 
close  to  the  anus.  The  object  of  this  groove  is  two-fold.  It  forms  a 
bed  in  which  the  ligature  can  be  sunk  tightl}^  and  above  all,  it  leaves 
a  ver}"  small  pedicle  of  tissues  to  be  strangled.  The  groove,  more- 
over, can  be  cut  without  risk  of  haemorrhage,  as,  however  large  the 
pile,  its  vessels  enter  it  from  above,  running  into  its  upper  part 
just  beneath  the  mucous  membrane.  The  surgeon  then  ties  round 
each  pile,  which  is  now  still  further  dragged  down,  a  ligature  of 
well  carbolized  silk,  the  strength  of  which  he  has  previously  tested. 
Sinking  this  into  the  groove  he  tightens  it  up  as  in  the  case  of  cas- 
tration with  the  aid  of  blunt  instruments  (Fig.  136).  About  two- 
thirds  of  the  pile  are  then  cut  away,  enough  being  always  left  to  en- 
sure a  safe  hold  for  the  ligature.  After  every  internal  pile  has  been 
carefully  treated  in  this  way,  the  external  ones  are  clipped  away,  care 
being  taken  not  to  encroach  upon  the  junction  of  skin  and  mucous 
membrane,  and  not  to  remove  subcutaneous  tissue  for  fear  of  subse- 
quent contraction.  If  any  bleeding-points  still  persist,  they  should 
now  be  tied.  The  ligatures  are  all  cut  short,  and  lastly  the  stumps  of 
the  piles,  smeared  with  iodoform  ointment  after  some  of  the  powder 
has  been  well  rubbed  in,  are  returned.  A  pad  of  lint  well  smeared 
with  the  same  ointment  is  then  applied  and  firm  pressure  made  with 
a  T-bandage  and  the  aid  of  a  pad  of  salicylic  wool,  carbolized  tow,  or 
"  tarred  cotton." 

ii.  Clamp  and  Cautery.— This  method  has  been  perfected  by 
Mr.  H.  Smith.f    The  preparatory  treatment  and  position  of  the  patient 

*  Eversion  of  the  rectal  mucous  membrane  by  a  finger  in  tlie  vagina  will  often 
be  most  helpful  in  bringing  piles  within  reach, 

t  Mr.  H.  Smith  {Si/st.  of  Surg  ,  vol.  ii.  p  840)  has  almost  entirely  discarded  the  use 
of  scissors,  removing  the  clamped  piles  with  heated  caiiterie-i  instead.  Three  of  these 
are  figured. 


824  OPERATIOXS  ox  THE  ABDOMEN. 

are  those  already  given.  The  piles  being  sufficiently  protruded,  with 
or  without  forcible  dilatation  of  the  anus,  they  are  drawn  well  down, 
one  by  one,  with  vulsellum  forceps,  and  enclosed  within  the  blades 
of  the  clamp,  which  is  screwed  tightly  up.  With  scissors  curved  on 
the  flat  the  pile  is  then  so  cut  away  as  to  leave  a  sufficient  stump. 
This  is  then  carefully  and  thoroughly  seared  down  with  a  Paquelin's 
cautery,  carefully  kept  at  a  dull  red  heat.  If  the  iron  sticks  at  any 
moment,  owing  to  its  cooling  down,  it  should  not  be  pulled  away,  but 
loosened  by  heating  it  up  a  little.  The  clamp-screw  is  then  slightly 
relaxed,  and  if  any  bleeding  takes  place  it  is  at  once  tightened  up, 
and  the  cautery  re-applied.  Every  care  must  be  taken  to  burn  down 
the  stump  thoroughly  at  the  first  attempt,  for  if  this  fail,  and  oozing 
take  place,  it  is  not  easy  to  stop  the  bleeding  from  the  tendency  of 
the  stump  to  slip  through  the  slackened  clamp.  Each  pile  having 
been  successively  dealt  with  in  this  way.  the  stumps  are  smeared  with 
iodoform  ointment  and  pushed  well  up  with  a  finger  coated  with  the 
same. 

iii.  Crushing. — This  method  has  recently  been  brought  before  the 
notice  of  the  profession  by  Mr.  Pollock*  and  Mr.  Benham.  It  is 
believed  to  be  less  painful  than  the  ligature,  and  to  leave  a  mere  thin 
and  superficial  fringe  of  dead  tissue,  instead  of  the  slough  of  the  clamp 
and  cautery.  The  patient  being  under  ether  each  pile  is  drawn  down, 
and  its  base  tightly  and  firmly  clamped.  The  projecting  part  is  then 
cut  away,  and  the  clamp  left  attached  for  from  two  to  four  minutes 
according  to  the  size.  Ligatures  must  be  applied  to  any  points  which 
still  bleed,  but  they  are  stated  to  be  rarely  required. 

iv.  Acid. — This  method,  formerly  much  over-rated,  should  be 
reserved  for  that  rare  variety  of  pile,  sessile,  perineal  usually  in  posi- 
tion, and  with  a  florid,  granular  surface.  Vaseline  being  applied 
around,  the  surface  of  the  pile  is  dried,  and  carefully  rubbed  over 
with  fresh,  strong  nitric  acid,  or  acid  mercury  nitrate,  this  being 
thoroughly  applied  with  a  glass  rod  or  pointed  bit  of  wood.  The  acid 
should  be  rubbed  in  and  in,  the  pile  being  kept  dry  and  the  acid  not 
allowed  to  run.  Every  atom  of  the  florid  surface  must  be  converted 
into  a  brownish,  shaggy  slough. 

Whitehead  st  Operation. — This  extensive  operation  is  intended 
to  bring  about  a  radical  cure,  its  object  being  not  only  to  remove  any 
existing  piles,  but  also  all  the  mucous  membrane  in  the  lowest  part 
of  the  rectum,  which  is  the  seat  of  piles,  owing  to  the  tendency,  of  its 
veins  to  become  dilated.  Though  Mr.  Whitehead  has  performed  it  in 
three  hundred  cases  without  a  fatal  result  or  any  drawback,  I  cannot 


*  Lancet,  vol.  ii.  1880,  p.  \,  et  passim.     The  clamp  used  is  here  figureii 
t  Brit.  Med.  Journ.,  February  26,  1887. 


HEMORRHOIDS.  825 

but  consider  it  needlessly  extensive  and  severe,  especially  in  patients 
of  middle  life,  and  in  a  part  which  cannot  be  kept  sweet,  even  with 
the  aid  of  iodoform.  The  operation  by  ligature,  or  by  clamp  and 
cautery,  carefully  performed,  gives  most  excellent  results,  and  in 
answer  to  Mr.  Whitehead's  argument,  that  as  long  as  this  diseased 
area  is  left  to  reproduce  piles  over  and  over  again,  no  permanent  cure 
can  be  expected,  I  may  say  that  I  have  always  found  that,  after  one 
of  the  above  operations  has  been  properly  carried  out,  the  patient  can 
easily  prevent  any  recurrence  by  attention  to  common-sense  details 
in  daily  life. 

Operation. — The  sphincters  being  thoroughly  dilated,  and  the 
hsemorrhoidal  area  of  mucous  membrane  made  to  prolapse,  the  line 
of  junction  of  skin  and  mucous  membrane*  is  looked  for,  and  the 
latter  divided  along  it  all  round  the  anus  with  blunt-pointed  scissors. 
The  cut  mucous  membrane  is  then  dissected  up,  with  forceps  and 
scissors,  from  off  the  external  and  (in  fact)  the  internal  sphincter  till 
the  whole  of  the  pile-producing  area  of  mucous  membrane  can  be 
drawn  outside  the  anus.  It  is  then  cutaway,  bit  by  bit,t  transversely 
at  its  still  attached  upper  border,  each  portion  as  cut  being  at  once 
attached  to  the  cut  skin  with  carbolized  silk  sutures.  In  this  way  the 
diseased  area-  is  removed  as  a  complete  ring  of  mucous  membrane. 
Each  bleeding-point  is  secured  by  torsion  or  forcipressure.  Iodoform 
is  dusted  over  the  wound.  The  sutures  are  allowed  to  come  away  of 
themselves. 

Causes  of  Failure  and  Trouble  after  Operations  for  Haem- 
orrhoids : 

1.  Htieinorrhage. —  This  will  not  occur  if  the  ligature  method  be 
carefully  employed.  If  the  surgeon  be  called  upon  to  meet  it,  the 
best  means,  in  a  severe  case,  is  Mr.  Allinghnm's  (^Dis.  of  the  Rectum,  p. 
122).  Through  a  conical  sponge  a  silk  ligature  is  threaded  from  apex 
to  base.  The  sponge,  well  dusted  with  iodoform  and  steel  sulphate, 
is  pushed  4  or  5  inches  into  the  bowel,  and  the  whole  of  the  space 
below  it  is  plugged  with  aseptic  gauze.  The  sponge  is  now  pulled 
down  by  the  two  ends  of  the  ligature  while  the  gauze  is  pushed  iq). 
The  plug  should  be  left  in  as  long  as  possible,  the  patient  being  kept 
under  the  influence  of  laudanum. 

2.  Tedious  Ulceration. — This  is  usually  due  to  the  patients  getting 
up  too  soon.  They  should  remain  in  a  bed  a  week  or  ten  days,  and 
then  be  content  to  pass  another  ten  or  fourteen  days  upon  the  sofa. 

3.  Septic  troubles. 

4.  Contraction. — This  is  only  likely  to  occur  when,  in  cutting  away 

*  The  '•  white  line"  of  Mr.  Hilton  {Rest  and  Pain,  p  289,  Figs.  51  and  52 >. 

f  So  as  to  diminish  tlie  haemorrhage,  which  would  otherwise  be  free  at  this  stage. 


826  OPERATIONS  OX  THE  ABDOMEN. 

piles,  especially  external  ones,  the  junction  of  skin  and  mucous  mem- 
brane is  trenched  upon. 

FISSURE.^-ULCER. 

The  oi^erative  treatment  of  these  is  so  simple  and  so  eminently 
successful,  that  it  should  be  resorted  to  early  in  these  cases. 

Operation  by  Incision. — The  preparatory  treatment  and  the 
position  of  the  patient  are  the  same  as  those  already  given.  The 
division  of  the  ulcer  may  be  performed  in  one  or  two  ways — (a)  From 
without.     (J))  From  within  the  rectum. 

(a)  From  loithout. — Here  the  ulcer  being  fully  exposed  with  a  specu- 
lum— and  the  one  which  bears  Mr.  Hilton's  name,  with  a  movable 
valve,  will  be  found  the  best — a  small  sharp-pointed  bistoury  is 
inserted  a  little  beneath  the  base  of  the  ulcer,  and  its  point  made  to 
protrude  in  the  bowel  above  it;  the  parts  are  then  divided  from 
without  inwards  through  the  centre  of  the  ulcer. 

(/))  From  within. — Here  the  ulcer  being  also  exposed,  either  by 
stretching  the  parts  with  two  fingers  or  with  a  speculum,  a  straight 
blunt-pointed  bistoury  is  drawn  across  the  whole  of  the  sore,  through 
its  centre.f  Mr.  Curling^  has  drawn  attention  to  an  important  point 
here,  and  that  is,  that  the  fibres  of  the  muscle  at  the  extremity  of  the 
ulcer  near  the  verge  of  the  anus  should  be  divided  rather  more  freely 
than  those  above,  so  as  to  avoid  an}'  ridge  or  shelf  on  which  the  fteces 
would  lodge. 

There  is  usually  no  lucniorrhage  to  speak  of,  and  the  whole  opera- 
tion is  so  simple  that  it  may  be  performed  after  an  injection  of 
cocaine,  or  with  nitrous  oxide  gas,  unless  anything  else — e.g.,  attention 
to  piles — is  required.  I  prefer,  however,  to  operate  with  ether  or 
chloroform. 

Of  the  two  methods,  I  generally  make  use  of  the  first,  following 
Mr.  Hilton.  I  consider  it  the  more  certain,  and  have  never  known 
of  anything  like  incontinence  in  the  nine  cases  in  which  I  have  used 
it.  The  second  is  rather  the  slighter  operation,  and  also  gives  good 
results. 

The  position  of  these  usually  club-shaped  ulcers  is  posterior.  If 
one  is  met  with  anteriorly  in  a  woman,  it  would  be  wiser  to  try  the 
application  of  acids,  or  the  actual  cautery.     See  foot-note,  p.  820. 

The  surgeon  must  be  careful,  when  examining  into  the  amount  of 
repair  a  week  or  two  later,  not  to  do  any  damage  with  a  speculum. 

*  This  condition,  often  called  a  fissure,  nearly  always  amounts  to  an  ulcer  when  it  is 
carefully  examined  and  the  i)arts  imfolded. 

t  Mr.  Cripps  (Dis.  of  Reclum  and  Anus,  p.  176)  say?,  ''so  as  to  divide  about  a  third 
of  the  fibres  of  the  external  spiiiiioter." 

X  Dis.  of  the  Rectum,  p.  12. 


PROLAPSUS.  827 

Operation  by  Dilatation  of  the  Sphincter. — This  is  not  only 
rough  but  uncertain,  and  should  not  be  employed, 

PROLAPSUS. 

Indications. — Failure  of  previous  treatment.  Large  size  and  long 
duration  of  prolapsus.  Altered  condition  of  the  mucous  membrane — 
viz.,  thickening  or  ulcers,  the  latter  giving  rise  to  haemorrhage-.  Incon- 
tinence of  faeces,  especially  when  fluid,  or  of  flatus. 

Operations. 

Acid.— Cautery,— Excision, 

1.  Acid. — Of  these  I  prefer  the  acid  nitrate  of  mercnry.  This 
method  is  especially  applicable  to  the  obstinate  <;ases  of  prolapsus  in 
children,  where  the  bowel  is  constantly  -down.  Though,  if  the  appli- 
cation is  made  properly,  onW  a  sensation  of  burning  is  com'plained  of, 
an  anesthetic  should  always  be  given.  The  patient  being  in  th« 
lithotomy  position  or  on  one  side,  the  prolapsus  is  carefully  dried  of 
all  mucus,  and  the  surgeon  rubs  in  the  acid  with  the  aid  of  a  glass 
rod  or  pointed  pieces  of  wood,  the  adjacent  skin  being  protected  with 
vaseline. 

Care  must  be  taken  not  to  rub  in  the  acid  too  long  or  too  vigorously, 
for,  if  the  inflammatory  i)rocess  set  up  affects  deeply  the  submucous 
tissue,  a  most  troublesome  stricture  may  readih'  result. 

It  is  well  to  warn  the  patients  that  a  second  application  may  be 
required  in  severe  cases. 

The  after-treatment  is  that  given  ])elow. 

2.  Cautery. — In  severer  cases,  or  where  the  acid  has  failed,  the 
following  will  be  found  efficient  The  position  of  the  patient  is  the 
same  as  that  above  given  but  it  is  best  to  apply  the  cautery  to  the 
bowel  in  situ,  though  this  may  be  used  when  the  bowel  is  prolapsed. 

Thus,  the  patient  being  in  lithotomy  position,  and  a  duckbill- 
speculum  introduced  and  held  in  contact  with  the  anterior  wall  of  the 
rectum,  the  blade  of  a  thermo-cautery  is  drawn  edgeways  along  the 
lower  three  or  four  inches  of  the  opposite  surface  of  the  gut.  The 
speculum  being  shifted,  the  anterior  and  lateral  aspects  are  similarlv 
treated  in  severe  cases. 

Care  must  be  taken  not  to  go  throur/h  the  mucous  membrane,  or 
septic  mischief  and  sloughing  may  be  set  up  in  the  cellular  tissue 
beneath. 

3.  Excision. — In  severe  cases,  in  adults,  when  other  methods  have 
failed,  this  method  should  be  resorted  to,  but  even  with  the  improve- 
ments of  the  present  day  there  must  always  be  a  difficulty  in  keeping 
wounds  here  aseptic. 

The  patient  being  in  lithotomy  position,  the  prolapsus  reduced,  and 


828  OPERATIONS  ON  THE  ABDOMEN. 

the  parts  exposed  by  a  duckbill-speculum,  two  or  more  elliptical 
pieces  of  mucous  membrane  are  removed  by  pinching  them  up  with 
a  vulsellum-forceps  and  cutting  them  away  with  a  very  sharp  scalpel 
or  scissors.  Any  bleeding  vessels  are  then  tied  with  chromic  gut,  and 
the  edges  of  the  wound  united  with  horsehair  or  fishing-gut  sutures,  a 
horsehair  drain  being  inserted  first.  Iodoform  is  then  carefully  dusted 
on,  and  the  parts  smeared  with  an  ointment  of  the  same. 

The  insertion  of  sutures  has  the  advantage  of  preventing  haemor- 
rhage, and  hastening  the  cure.  The  disadvantage  is  that  an  ana-esthetic 
will  probably  be  required  for  their  removal.  Especial  care  will  be 
needed  now  not  to  break  down  the  union  with  the  speculum.  The 
wounds  must  be  well  washed  daily  with  a  small  Higgenson's  syringe. 

After-Treatment. — After  any  operation  for  prolapsus,  the  patient 
must  rest  for  three  weeks  on  the  sofa  to  allow  of  firm  consolidation 
and  cicatrization  taking  place.  Light  diet — mainly,  milk — should  be 
allowed  at  first,  and  the  bowels  should  only  be  allowed  to  act  every 
three  days,  and,  if  possible,  while  the  patient  is  on  his  side. 

EXCISION  OF  THE  RECTUM. 

Indications.     Suitable  cases. 

1.  Malignant  disease  of  anus — e.^'.,  papillomata,  or  old  condylomata 
becoming  epitheliomatous,or  epithelioma  originating  in  some  neglected 
fistula. 

2.  Malignant  disease  of  rectum. — The  extent  and  fixity  of  this  must 
be  most  carefully  investigated.  If  limited  to  the  posterior  wall  of  the 
rectum  even  4  or  4^  inches  of  bowel  may  be  removed.  If  the  disease 
have  attacked  the  sides  or  the  circumference,  three  inches  in  the  male, 
but  less  than  this  in  the  female,  may  be  removed  as  long  as  the  bowel 
is  fairly  movable  on  subjacent  parts.  This  point,  especially  in  the 
male,  is  rather  difficult  to  decide,  as  even  a  normal  rectum  is  closely 
connected  to  the  prostate  and  urethra  and  base  of  the  bladder.  Mr. 
Cnpps*  (Dis.  of  Rectam  and  Amis)  thinks  that  though  the  bowel  in 
contact  with  the  prostate  may  be  diseased,  it  is  a  long  while  before  the 
prostate  itself  becomes  infected  ;  in  women,  on  the  contrary,  Avhen  the 
disease  is  on  the  anterior  part  of  the  bowel,  the  vagina  and  uterus 
quickly  become  implicated. 

Mr,  Allingham  (Intern.  Eiicyd.  of  Sarg.,  vol.   vi.  p.  122),  from  an 


*  This  surgeon,  who  has  had  large  experience  of  this  operation,  writes  :  ''  It  is  well 
to  remember  in  the  female  how  near  to  the  perineum  the  peritoneal  membrane 
descends,  it  being  much  more  commonly  at  a  shorter  distance  than  3  inches  than  at  a 
distance  in  excess  of  that  measurement.  In  the  male,  however,  3h  to  4  inches  from 
the  anus  is  the  common  site  for  the  reflection  of  the  peritoneal  membrane. 


EXCISION    OF   THE    RECTUM.  829 

experience  of  thirty-six  cases  *  considers  that  "  extirpation  of  the 
rectum  may  be  undertaken  in  any  form  of  cancer  which  does  not 
necessitate  the  removal  of  more  than  4f  or  5  inches  in  the  male,  and 
about  1  inch  less  in  the  female." 

Most  surgeons  will,  however,  not  care  to  remove  more  than  3  inches 
of  the  bowel,  as  beyond  this  limit  the  risks  increa-se  rapidly.  It  is  not 
only  that  the  limit  of  the  peritoneum  vari<?s  normally,  but  further,  it 
can  never  be  told  how  far  the  carcinoma  has  drawn  this  downwards. 
The  risk  of  opening  the  peritoneum  is  referred  to  below. 

After  all,  measurements  are  of  small  service  here.  The  chief  points 
are — U)  Can  the  finger  be  got  well  above  the  disease  without  feeling 
any  scattered  nodules  here  ?  (2)  Is  the  disease  movable  on  adjacent 
parts  ? 

3.  There  must  be  no  enlargement  of  liver,  or  pelvic  or  inguinal 
glands. 

4.  The  patient's  general  condition  must  be  sufficiently  good  to  meet 
the  calls  of  wdiat  may  be  a  very  severe  operation. 

Comparison  between  Excision  of  the  Rectum  and  Co- 
lotomy. — The  chief  points  calling  for  attention  are — (i)  The  mortality 
of  the  operation,  (ii)  The  duration  of  life  after  it.  (iii)  The  amount 
of  comfort  given  by  it. 

(i)  The  Mortality  of  the  Operation. — In  instituting  a  -comparison  on 
these  heads  between  colotomy  and  excision  of  the  rectum  it  must,  I 
think,  always  be  remembered  that  in  one  respect  the  lattei"  operation 
is  never  performed  under  those  unfavorable  conditions  of  obstruction 
which,  owing  to  the  operation  being  often  deferred  till  too  late,  render 
the  mortality  of  colotomy  such  a  high  one.  Turning  to  the  mortality 
of  excision  by  itself  without  comparison  with  any  other  operation,  we 
find  that  Mr.  Butlin,t  who  has  collected  one  hundred  cases  from 
various  sources,  gives  a  mortality  of  35,  This  death-rate  of  one-third 
he  regards  as  far  too  high,  and  as  capable  of  reduction  by  one-half,  or 
even  more,  by  attention  to  antiseptic  details  and  also  by  abandoning 
the  practice  of  drawing  down  and  suturing  the  cut  bowel,  a  practice 

*  Of  3(5  cases  operated  on  since  1874,  Mr.  Allingham  has  been  able  to  trace  2G.  Of 
these — 

1  died  about  4  years  after  the  operation. 

1  "         "      3    ■"            "  " 

2  "  "  2  "  "  " 
5  "  over  18  months  "  '^ 
7     "     about  1  year          "  " 

5     "     from  the  direct  consequences  of  the  operation, 
5  are  known  to  be  still  alive, 
f  Oper.  Surg.  Malig.  Dis.,  p.  24L 


830  OPEKATIOISrS   ON    THE   ABDOMEW. 

which  has  been  largely  followed  at  Vienna,  and  which,  by  causing 
retro-peritoneal  suppuration,  has  greatly  increased  the  mortality. 
While  Mr.  Butlin's  criticism  is,  no  doubt^  a  sound  one,  I  venture  to 
think  that  another  poin^t  has  ]>een  overlooked  which  will  prevent  any 
real  reduction  in  the  death-rate  of  excision.  In  this,  as  in  every  other 
novel  and  important  operation,,  a  large  number  of  unsuccessful  cases 
will  remain  unpublished,  while  every  successful  ease  is  reported  at 
once. 

(ii)  Duration  of  Life. — With  regard  to  this  point,  I  think  a  larger 
number  of  cases  will  show  that  if  the  surgeon  decides  to  advise,  and 
the  patient  is  willing  to  run  the  risk  of^  the  more  serious  operation,  the 
prolongation  of  life  will  be  greater  here  than  after  colotomy.  Excision 
of  the  rectum,  if  it  does  not  extirpate  the  disease  completely,  may  do 
so  locally,  leading  to-  a  more  merciful  death  by  \asceral  deposits. 
Again,  excision  of  the  rectum,,  if  only  temporarily  successful  locally, 
and  recurring,  may  be  repeated  if  the  recurrence  is  detected  early,  and 
it  may  also  be  s-upplemented  by  colotomy,  each  of  these  fresh  opera- 
tions giving  addition  of  life  in  properly  selected  cases.  I  think  that 
the  above  is  borne  out  by  the  results  of  the  statistics  which  we  have. 
It  is  rare  for  patients  after  colotomy  for  carcinoma  to  survive  more 
than  one  year  and  a  half.  Making  due  allowance  for  the  advanced 
date  at  which  cases  of  rectal  cancer  too  often  come  under  treatment, 
for  the  fact  that  excision  will  usually  be  performed  in  selected  cases, 
and  that  thus  colotomy  will  be  reserved  for  those  less  favorable,  I  think 
the  published  cases  of  excision  show  a  greater  prolongation  of  life. 
Mr.  Cripps  speaks  of  six  cases  known  to  have  been  well  at  periods  of 
two  to  four  years  after  the  excision,  one  of  these  showing  the  value  of 
a  second  operation.  Mr.  Allingham's  cases  (p.  829)  show  that  in  four 
death  took  place  over  two  years  after  the  operation,  and  that  nine  sur- 
vived over  eighteen  months.  Mr.  Butlin  quotes  two  cases  of  Fischer's 
claimed  as  complete  cures,  one  of  six  yes.rs'  duration,  the  other  of  three 
years  and  ten  months. 

(iii)  Amount  of  Comfort  Afforded. — After  this  operation,  as  after 
excision  of  the  larynx,  a  distinction  must  be  drawn  between  mere 
survival  and  what  deserves  the  name  of  recovery.  The  amount  of 
comfort  enjoyed  by  the  patient  will  depend  on — (1)  The  amount  of 
contraction  that  takes  place.  (2)  How  far  he  has  control  over  his 
motions.  Where  the  whole  circumference  of  the  bowel  has  been 
removed,  a  matter  referred  to  below  (p.  833),  it  is  obvious  that  there 
must  be  a  great  risk  of  contraction  in  the  scar-tissue  which  replaces 
the  mucous  membrane.  This  tendency  will  be  most  marked  in  the 
lower  inch  or  two,  for  Mr.  Cripps  finds  that  the  severed  end  of  the 
bowel  is  drawn  considerably  downwards  during  the  process  of  healing. 


EXCISION    OF    THE    RECTUM.  831 

This  renders  it  easier  for  the  patients  to  pass  a  bougie  from  time  to 
time,  the  need  of  which  must  be  firmly  impressed  upon  them. 
Another  means  of  securing  the  patency  of  the  bowel  is  by  wearing  a 
vulcanite  tube,  as  recommended  by  Mr.  Allingham.  These  are  3  or  4 
inches  long,  with  one  end  conical,  and  with  the  other  ending  in  a 
broadish  flange  to  prevent  its  slipping  into  the  bowel,  and  also  to 
enable  it  to  be  stitched  to  a  bandage  which  keeps  it  in  place.  Patients 
begin  to  wear  it  about  a  fortnight  after  the  operation,  and,  save  for 
taking  it  out  when  the  bowels  act,  retain  it  constantly  for  some  months, 
some  having  to  wear  it  for  the  rest  of  their  lives. 

As  to  the  power  of  retaining  faeces,  incontinence  is  always  present 
at  first,  but  control  is  usually  regained  after  a  time.  Mr.  Cripps  Hoc. 
supra  cit.)  states  that  incontinence  was  present  in  only  seven  out  of 
thirty -six  cases  which  he  collected.  As  he  points  out,  the  last  few 
inches  of  the  rectum  are  empty  in  health  during  the  greater  part  of 
the  da\',  faeces  l^eing  onl}^  occasionally  brought  into  contact  with  the 
sphincter  either  by  diarrhoea,  or  by  straining  of  the  abdominal  mus- 
cles. As  therefore  the  normal  condition  of  the  last  few  inches  is,  dur- 
ing health,  one  of  emptiness,  a  narrow,  long,  valve-like  chink  may  be 
found  efficient  after  operation,  especially  if  tortuous. 

Operation  of  Excision  of  Rectum  in  its  Entire  Circumfer- 
ence.— The  bowels  being  well  emptied  by  mild  purgatives  and  an 
enema,*  the  patient,  under  the  influence  of  ether,  is  placed  in  lith- 
otomy position,  and  the  surgeon  rapidly  makes  an  oval  incision  into 
both  ischio-rectal  fossaj,  around  the  bowel,  then  prolonging  this  oval 
backwards  so  as  to  reach  the  coccyx. 

This  backward  prolongation  is  much  needed  in  order  to  give  addi- 
tional room  for  meeting  h8emorrhage,t  and  for  providing  drainage 
later  on.  The  fingers,  aided  if  needful  by  the  knife  or  blunt  dissector, 
separate  the  bowel  at  the  sides  and  posteriori}'-  as  high  as  the  levator 
ani ;  the  haemorrhage  in  this  stage  is  usually  not  severe,  and  can 
be  readily  arrested  by  pressure-forceps,  or  sponges  pushed  into  the 

*  Mr.  Barker  {^fan.  of  Surg.  Oper.,  p.  313)  recommends,  in  addition  to  co()ioiis  ene- 
luata  on  the  morning,  an  enema  of  brandy  before  the  operation,  as  a  general  stimulant 
and  an  antiseptic. 

t  If  this  incision  has  to  be  carried  as  higli  up  as  3  or  4  inclies,  the  hieniorrhage  will 
be  free,  as  the  superior  haemorrhoidal  artery  here  divides  into  two  terminal  branches. 
The  free  incision,  well  opened  out  with  retractors,  will  admit  of  easily  dealing  with 
this  vessel.  Another  method  is  to  begin  by  a  free  posterior  incision,  made  by  guid- 
ing a  curved  sharp  bistoury  well  above  the  disease  in  the  posterior  wall,  bringing  out 
the  point  at  the  tip  of  the  coccyx,  and  then  cutting  all  the  intervening  tissues  into  the 
bowel.  This  exposes  well  the  limits  of  the  growth.  If  the  first  metliod  is  made  use 
of,  the  bowel  must  be  laid  open  subsequently,  to  investigate  the  upper  limits  of  the 
disease. 


832  OPERATIONS  ON  THE  ABDOMEN. 

incision.  The  separation  of  the  bowel  in  front  varies  with  the  sex  of 
the  patient.  In  the  male  a  full-sized  metal  sound  being  passed  into 
the  bladder  *  the  surgeon  carefully  dissects  away,  partly  with  his 
finger  and  partly  with  scissors,  between  the  bowel  and  urethra  and 
prostate.  These  parts  are  naturally  adherent,  and  this  dissection  must 
be  carefully  conducted  as  any  opening  into  the  bladder  or  urethra 
will  much  increase  the  shock.  In  the  case  of  a  woman  the  surgeon's 
left  index,  or  the  finger  of  an  assistant  in  the  vagina,  will  give  the 
best  warning  of  his  knife  or  scissors  getting  too  near  the  vaginal 
mucous  membrane.!  If  this  be  encroached  upon  it  must  be  removed 
without  hesitation,  in  the  hope  that  the  cloaca  thus  formed  will  be 
much  diminished  by  contraction,  or  that  it  may  be  closed  subse- 
quently. If  the  disease  has  extended  up  the  recto-vaginal  septum 
the  peritoneum  must  be  looked  out  for,  and  the  greatest  care  taken 
not  to  open  this  cavity  at  the  upper  part  of  the  dissection.  The 
levator  ani  being  carefully  cut  through,  the  rectum,  now  separated 
everywhere  save  above,  is  dragged  down  by  an  assistant  or  by  the 
operator  with  his  left  hand.  While  this  tension  is  kept  up,  the  sur- 
geon with  his  finger,  aided  by  scissors,  frees  the  bowel  sutficiently 
above  the  disease  to  admit  of  drawing  it  safely.  Frequent  examina- 
tion of  the  interior  of  the  bowel  should  be  made  at  this  stage  to  tell 
when  the  upper  limit  of  the  disease  has  been  reached.    ' 

When  the  bowel  has  been  safely  isolated  above  the  disease  it  must 
be  divided  either  with  the  wire  loop  of  an  ecraseur,  as  recommended 
by  Mr.  Cripps,  or  by  scissors.  WTien  the  patient  is  in  good  condition, 
where  little  blood  has  been  lost,  and  where  the  operation  has  not  been 
much  prolonged,  division  by  scissors  is  to  be  recommended,  as  these 
give  a  much  cleaner-cut  surface,  and  one  therefore  less  liable  to  slough, 
and  they  furthermore  avoid  the  risk  which  is  inseparable  from  the  use 
of  the  ecraseur — viz.,  its  gradually  encroaching,  as  it  is  tightened, 
more  and  more  closely  upon  the  diseased  area. 

If  the  surgeon  is  unprovided  with  an  ecraseur  he  may  divide  the 
rectum  with  a  Paquelin's  cautery.  But,  as  remarked  by  Mr.  Cripps, 
the  use  of  any  form  of  cauter}'  during  the  operation  makes  it  ex- 
ceedingly difficult  to  distinguish  between  the  hard  nodules  of  burnt 
tissue  and  portions  of  the  disease  left  behind. 

The  bowel  having  been  removed,  all  bleeding-points  are  most  care- 
fully looked  for,  and  the  wound  is  thoroughly  dusted  over  with  iodo- 

*  Prof.  Macleod  {loc  supra  cil.)  advises  that,  if  the  disease  is  low  down,  it  matters 
little  whether  the  bladder  is  full  or  empty  ;  if  a  higher  portion  has  to  be  dealt  with,  as 
Dupuytren  showed,  the  nrine  should  be  retained,  so  as  to  raise  the  recto- vesical  pouch. 

f  Subsequent  sloughing  here  is  not  unlikely. 


EXCISION    OF   THE    RECTUM.  833 

form,  painted  over  with  this  antiseptic  and  ether  *  and  lightly  plugged 
with  strips  of  aseptic  gauze. t 

If  the  peritoneum  has  been  opened,  either  a  drainage-tube  packed 
around  with  gauze,  or  a  tampon  of  gauze,  must  be  made  use  of. 

Mr.  Cripps  considers  that  ixny  attempt  to  bring  down  the  edges  of 
the  cut  rectum  and  to  stitch  them  in  situ  around  the  anus  is  perfectly 
useless,  as  the  sutures  are  certain  to  cut  their  way  out,  and  harmful, 
as  likely  to  prevent  the  escape  of  discharges.  As  this  runs  the  very 
serious  risk  of  septicaemia,  the  advantages  which  suturing  the  bowel 
would  give,  if  it  were  safe,  of  preventing  subsequent  contraction,  must 
be  put  aside. 

Question  of  Partial  Removal.— If  any  of  the  mucous  mem- 
brane, even  a  mere  stri}),  can  lie  ■'<((fcfu  left,  the  amount  of  subsequent 
contraction  will  be  less,  but  here,  as  in  all  other  operations  for  malig- 
nant disease,  every  consideration  must  give  way  to  the  chief  object, 
that  of  extirpating  the  growth. 

Partial  operations  should  be  reserved  only  for  cases  where  the  dis- 
ease is  very  localized  in  amount,  and  admits  of  extirpation,  together 
with  a  very  wide  margin  of  bowel.  Where  the  disease  implicates 
one-half  of  the  bowel,  even  if  apparently  not  disseminated  in  the 
mucous  membrane,  the  whole  circumference  should  be  removed.  Mr. 
Allingham  thus  condemns  partial  operations :  "  The  partial  removal 
of  the  circumference  of  the  bowel  is,  in  my  opinion,  most  unsatis- 
factory. In  all  the  cases  in  which  I  have  removed  only  part  of  the 
wall,  there  has  been  either  a  return  of  the  disease  in  the  rectum,  or  in 
the  glands  in  the  groin,  or  in  some  internal  organ,  mostly  the  liver." 

If  the  surgeon  decide  on  a  partial  operation,  he  must  be  prepared 
for  some  increased  difficulty,  owing  to  the  diminished  room  for  work- 
ing, and  meeting  the  haemorrhage.  Perhaps  only  one  semilunar  inci- 
sion around  the  anus  will  be  required.  Mr.  Cripps  thus  advises  the 
use  of  the  ecraseur :  "  A  strong,  blunt-pointed,  slightly  curved  needle, 
4  inches  in  length,  armed  with  strong  string,  is  then  thrust  in  at  the 
upper  angle  of  the  curved  lateral  incision,  at  a  point  opposite  the 
posterior  preliminary  incision,  or  further  round  if  the  disease  has 
encroached  at  all  on  the  anterior  wall.  The  needle  is  made  to  traverse 
the  tissues  external  to  the  muscular  coat  of  the  bowel  to  a  sufficient 
height,  and  the  point,  guided  by  the  finger  in  the  rectum,  is  thrust 
through  the  coats  into  the  cavit}^  of  the  bowel.  The  loop  of  string 
thus  passed  through  is  seized  and  drawn  out  at  the  anus,  while  the 

*  Throughout  the  operation  the  wound  should  be  well  syringed  witii  a  .solution  of 
mercury  perchloride  (1  in  2000).  This  should  be  used  hot,  if  there  is  troublesome 
oozing. 

f  If  it  is  necessai-y  to  do  this  firmly,  the  pings  should  be  removed,  by  soaking,  as 
soon  as  possible,  in  order  to  allow  of  escape  of  discharges. 

53 


834  OPERATIONS    ON    HIE    ABDOMEN'. 

needle  is  withdrawn  through  the  hole  at  which  it  entered.  By  means 
of  this  loop  one  end  of  an  ecraseur  wire  is  drawn  back  into  the  bowel 
and  out  again  at  the  puncture  made  l)y  the  needle.  This,  together 
with  the  other  end  of  the  wire  which  hangs  out  of  the  rectum,  are  fixed 
to  the  ecraseur,  and  the  intervening  tissues  cut  through.  The  strip 
of  bowel  between  the  posterior  incision  and  the  one  just  made  by  the 
ecraseur  can  now  be  separated  by  the  finger  from  its  lateral  connec- 
tions, the  separation,  of  course,  commencing  from  the  semilunar  in- 
cision round  the  anus.  In  this  way  the  rectangular  flap  of  bowel  in 
which  the  disease  is  situated  is  detached  from  the  surrounding  connec- 
tions, except  at  its  upper  margin.  It  is  then  drawn  down  and  cut  off 
by  the  ecraseur  or  scissors.  It  can  be  readily  understood  how  the 
steps  of  this  operation  must  depend  upon  the  portion  of  bowel  in 
vvhich  the  disease  is  situated.  If  it  be  in  the  middle  line  behind,  the 
disease,  or  a  portion  of  it,  will  probably  have  been  split  by  the  first 
incision,  in  wdiich  case  a  strip  cf  bowel  must  be  removed  on  either 
side;  or  again,  if  it  be  on  the  anterior  wall,  tlie  ecraseur  wire  will 
have  to  be  twice  passed  by  the  thread  and  needle,  once  in  each  side 
of  the  disease,  or  instead  of  the  ecraseur  all  the  cutting  can  be  done 
with  scissors  if  preferred." 

After-treatment. — The  chief  points  here  are  to  keep  the  wound 
sweet  by  frequent  syringing  with  dilute  mercury  perchloride  solutions, 
or  Condy's  fluid,  and  the  insufflation  of  iodoform.  The  catheter  will 
probably  be  required,  and  a  mild  aperient  may  be  given  about  the 
sixth  day,  if  needed.  The  finger  should  be  occasionally  passed  with 
the  utmost  gentleness,  and  after  a  week  or  ten  days,  a  tallow  candle, 
succeeded  later  by  a  bougie. 

Causes  of  Trouble  and  Failure  after  Excision  of  the 
Rectum. 

1.  Shock. 

2.  Haemorrhage.  This  will  rarely  be  difficult  to  deal  with  at  the 
time,  or  met  with  later,  if  the  surgeon  has  plenty  of  Spencer  Wells's 
forceps,  good  assistants,  and  if  he  does  the  operation  steadily,  con- 
trolling each  vessel  as  met  with.*  This,  aided  by  hot  injections  (p. 
833)  and  firm  sponge  pressure,  will  usually  prevent  any  secondary 
haemorrhage.  If  this  should  occur,  Prof.  Macleod's  advice  should  be 
followed — viz.,  to  pass  a  large  tube  into  the  bowel  for  the  escape  of 
flatus,  etc.,  and  to  pack  carbolized  sponges,  or  strips  of  gauze,  firmly 
round  this. 

3.  Suppuration.     Cellulitis  and  other  septic  troubles. 

*  Mr.  Cripps  has  shown  that,  as  most  of  the  bleeding  comes  from  vessels  situated  in 
tlie  walls  of  the  rectum,  dragging  down  the  bowel  with  a  firm  grasp  will  not  only 
greatly  facilitate  the  operation,  but  also  prevent  haemorrhage. 


IMPERFORATE    ANUS    AND    RECTUM. 


835 


4.  Peritonitis. 

5.  Exhaustion. 
•   6.  Recurrence. 

IMPERFORATE  ANUS.— ATRESIA  ANI.— IMPERFECTLY 
DEVELOPED  RECTUM  (Figs.  137-143). 

A  surgeon,  when  called  upon  to  explore  these  cases,  will  do  well  to 
bear  in  mind  the  following  natural  and  practical  classification,  because 
on  this  depends  his  treatment: 

Tico  Main  Varieties: 

A.  Cases  in  which  no  normal  anus  exists — Imperforate  Anus. 

B.  Cases  in  which  a  normal  anus  exists,  but  the  gut  is  obstructed 
higher  up,  or  undeveloped — Imperforate  Rectum. 

A.  Imperforate  Anus. 

1.  Anus  partially  closed — (a)  bj'  adhesions  of  epithelial  surfaces,  as 
occasionally  happens  in  the  labia  of  a  female  infant;  (b)  by  a  mem- 
brane. 

2.  Anus  completely  closed,  but  only  by  a  membrane. 

3.  Anus  completely  closed  by  a  membrane,  but  a  fistula  exists — (a) 
on  the  surface  of  the  body  (e.g.,  the  raphe  of  the  scrotum);  (b)  into 


Fig.  137 


Fig.  138. 


Fir,.  139. 


Anus  absent.  Rectum  open-  Anus  absent.  Rectum  com-  Anus  ending  in  cul-de-sac. 
ing  by  fistula,  close  to  urethra,  municating  with  vagina.  Rectum  opening  into  urethra 
(Rushton  Parker.)  (Rushton  Parker.)  far  back.     A  case    for  Littre's 

operation.    (Rushton  Parker.) 


the  vagina,  Fig.  138;  (c)  into  the  urethra  or  bladder.  Figs.  137,  139, 
143. 

4.  Anus  imperforate  and  the  rectum  deficient  as  Avell. 

B.  Anus  in  natural  position,  but  the  rectum  is  deficient* — (a)  the 

*  Tliis,  :iiid  the  next  six  figures,  are  taken  (with  a  few  alterations)  from  an  article 
by  Mr.  Rushton  Parker  {Liverpool  Med.  Chron.,  July,  1883). 

t  As  Mr.  Holmes  has  shown,  these  eases  are  important,  as  they  are  liable  to  be 
overlooked  till  considerable  distension  has  taken  place. 


836  OPERATIONS  ON  THE  ABDOMEN. 

rectum  is  deficient  for  a  sliort  distance  only,  and  separated  from  the 
anus  by  a  cul-de-sac,  Fig.  141 ;  {b)  the  rectum  is  deficient  for  a  long 
distance,  or  entirely,  Fig.  142. 

Treatment. 

A.  Those  in  which  no  natural  anus  exists. 

1  and  2.  If  tlie  atresia  be  due  to  epithelial  adhesions,  or  to  a  more 
or  less  complete  membrane,  the  former  should  be  broken  down  and 
the  latter  snipped  away  with  scissors,  and  the  opening  kept  patent  by 
a  small  piece  of  oiled  lint,  the  nurse's  little  finger  being  introduced 
twice  daily. 

3.  If  the  anus  be  imperforate,  and  a  fistula  open  (a)  on  the  surface  of 
the  body,  (6)  into  the  vagina,  or  (c)  urethra. 

(a)  A  probe  is  passed  from  the  skin-fistula  (e.g.,  in  the  scrotum) 
towards  the  proper  anal  site  ;  it  is  then  cut  down  upon  and  the  open- 
ing established  in  the  proper  position. 

(b)  If  tlie  fistula  0})en  into  the  vagina,  the  treatment  will  vary 
somewhat  with  the  urgency  of  the  case,  the  size  of  the  opening,  and 
the  age  of  the  child. 

Thus,  if  the  opening  be  very  small  and  the  retention  urgent,. a  silver 
director  should  be  passed  through  the  vaginal  fistula  back  to  the 
proper  site  of  the  anus,  and  there  cut  down  upon.  If  the  bowel  is 
within  reach,  it  should  be  drawn  down  and  stitched  in  situ.  The 
orifice  should  be  kept  patent.* 

If,  owing  to  the  size  of  the  vaginal  fistula,  there  is  not  much  reten- 
tion, and  especially  if  the  child  be  not  very  young,  the  following 
operation  may  be  performed,  after  the  method  of  S.  Rizzoli  (quoted 
by  Mr.  Holmes,  Syst.  of  Surg.,  vol.  iii.  p.  788) :  An  incision  is  made 
from  the  vulva  to  the  coccyx  in  the  middle  line,  the  rectum  found  by 
most  careful  dissection,  separated  from  the  vagina,  and  then  brought 
down  and  fixed  in  its  natural  position.  To  aid  in  finding  the  rectum, 
a  probe  will  be  passed  from  the  fistula. 

After  the  rectum  has  been  brought  down  and  secured,  the  incision 
between  the  anus  and  vulva  is  united  to  form  a  new  ])erineum. 

(c)  Fistula  into  the  urethra  or  bladder.  Two  questions  here  arise  : 
How  high  up  is  the  communication?  How  much  of  the  bowel  is 
deficient? 

If  the  perineum  seem  fairly  developed,  if  the  ischial  tuberosities  are 
not  in  close  contact,  if  any  bulging  can  be  detected  at  the  natural  site 
of  the  anus,  the  communication  is  probably  recto-urethral,  and  an 
attempt  may  reasonably  be  made  to  find  the  bowel  from  the  perineum 

*  In  siH'li  a  case,  tiiongh  an  anus  if  established  in  the  proper  position,  it  is  very 
donbtful  if  the  vaginal  fistnla  will  close,  and  a  further  operation  will  prol)ably  be 
reqnired  later  on.  Plastic  operations  shonld  not  be  tried  too  early  on  account  of  the 
softness  of  the  tissues  and  the  li(]nid  condition  of  the  fsrces. 


IMPERFORATE    A  XL'S    AND    RECTUM. 


831 


(p.  838).     If  it  is  found,  and  can  be  brought  down,  an  attempt  may 
be  made  to  separate  it  from  the  adjacent  urethra,  but  usually  tlie  sur- 


FiG.  140. 


Fig.  141. 


Anus  absent.    Rectum  could  be  readied  by 
dissection.    (Rushton  Parker.) 


Anus  ending  in  cul-de-.sac.    Rectum  readily 
reached  from  this.    (Rushton  Parker.) 


geon  will  have  to  be  satisfied  with  a  free  opening,  and  with  keeping 
this  patent,  so  as  to  encourage  the  urethral  connnunication  to  close. 


Fig.  142. 


Fig.   143. 


Anus  absent.  Rectum  ending  high  up.  A  case 
for  Littre's  operation.  (Rushton  Parker.) 


Anus  and  rectum  deficient,  the  bowel  ending 
in  the  bladder.    (Rushton  Parker.) 


If  there  appear  no  probability  of  the  bowel  being  within  reach,  or  if 
this  cannot  be  found,  Littre's  operation  should  be  performed  (p.  605).* 

4.  Anus  absent  and  rectum  deficient  as  well.  Here  the  chief 
question  is  how  far  upwards  an  exploratory  operation  ma}-  be  safely 
conducted. 

External  evidence.  Genitals  far  back  and  close  to  the  coccyx,  and 
ischial  tuberosities  close  together,  point  to  absence  of  the  rectum. 


*  If  ilie  child  survive,  the  bladder  must  be  kept  carefully  washed  out  if  any  fa>ces 
still  find  their  way  into  it.  Thus,  in  a  case  of  Mr.  Glutton's  {St.  Thomas's  Hosp.  Benorls, 
vol.  xi.  p  84>,  a  oiiild  about  a  month  old  died,  sixteen  days  after  Littrfe's  operation 
of  suppurating  kidneys,  due  to  the  offensive  purulent  urine. 


83S  OPERATIONS  ON  THE  AHDOMEX, 

In  most  cases  the  surgeon  begins  by  exploring.  The  child  being 
under  ether  and  in  lithotomy  position,  with  a  small  sandbag  under 
the  sacrum,*  the  surgeon,  seated  at  a  comfortable  level,  makes  a  free 
incision  from  the  position  of  the  anus  back  to  the  coccyx.  Keeping 
exactly  in  the  middle  line,  and  opening  up  the  cellular  tissue  with  his 
finger-tip,  aided  by  a  scalpel  and  director,  the  surgeon  w^orks  back- 
wards towards  the  concavity  of  the  sacrum,  constantly  taking  note 
with  his  finger-tip  of  the  depth  to  which  he  has  got,  while  an  assistant 
aids  to  bring  down  the  bowel  by  supra-pubic  pressure. 

As  a  rule,  two  inches  are  a  sufficient  deptli  in  a  new-born  child- 
If  still  in  doubt  whether  to  proceed  or  no,  the  surgeon  mny  make  a 
careful  ])uncture  with  a  morphia-syringe  backwards,  and  note  the 
condition  of  the  point;  no  puncture  with  a  trocar  is  justifiable  at  this 
depth. 

Points  to  bear  in  mind. — 1.  The  rectum  may  end  at  the  brim  of  the 
pelvis.  2.  If  it  end  lower  down  it  may  be  floating  with  a  long  meso- 
rectum.  3.  Though  the  rectum  may  end  within  reach,  the  peritoneum 
may.  and  not  unfrequently  does,  extend  low  down  on  the  bowel.  4. 
Even  if  the  rectum  is  successfully  opened  high  up,  without  opening 
the  peritoneum,  fatal  cellulitis  may  be  set  up  by  the  escaping  faeces, 
or  by  the  attempts  to  keep  the  bowel  patent. 

If  the  above  exploratory  operation,  fail,  inguinal  colotomy  or 
Littre's  operation  should  be  resorted  to,  p.  605. 

B.  Iinperforate  Rectum.. — The  treatment  here  will  be  an  exploratory 
operation  (p.  838),  followed,  in  case  of  failure,  by  Littre's  operation 
(p.  605). 


CHAPTER  XVI. 

RUPTURED  PERINEUM  (Figs.  144,  145). 

The  following  account  is  taken  from  my  colleague,  Dr.  Galabin  :t 
A.  Operation  for  Partial  Rupture  (Fig.  144). — "The  patient 
is  placed  in  the  lithotomy  position.  The  need  for  assistants  to  support 
the  thighs  is  avoided  if  'Clover's  crutch '  is  used.  By  this  the  thighs, 
just  above  the  knees,  are  fixed  by  circlet  straps  at  the  end  of  an  iron 
bar,  the  length  of  which  can  be  regulated  by  a  screw  which  fixes  it  in 
any  position.  The  thighs  are  then  flexed  to  any  required  degree  by 
a  padded  strap  which  passes  from  one  end  of  the  bar  round  the  neck, 
and  is  then  attached  to  the  other  end.     Thus,  the  knees  can  be  kept 

*  The  bladder  may  first  be  emptied  with  a  catheter. 

f  Dis.  of  Women,  pp.  130,  381      Any  one  making  a  trial  of  this  metliod  will  agree 
with  me  as  to  its  simplicity  and  excellent  results. 


RUPTUItED    PERINEUM. 


839 


widely  apart  while  the  operation  is  performed,  and  brought  closer 
together  by  altering  the  screw,  when  tlie  time  arrives  for  tightening 
the  sutures. 

"The  extent  of  surface  to  be  freshened  is  indicated,  to  some  extent, 
by  the  cicatrix  left  by  the  rupture.  It  is  Avell,  however,  to  go  a  little 
bej'ond  the  limits  of  this  in  all  directions,  especially  up  the  median 
line  of  the  vagina  and  towards  the  lower  halves  of  the  labia  majora, 
both  in  order  to  secure,  if  possible,  a  perineal  body  somewhat  larger 

Fig.  144. 


(Galabin.) 

and  deeper  than  the  original  one,  and  to  allow  some  margin,  in  case 
the  surfaces  do  not  unite  completely  up  to  the  edges.  To  put  the 
mucous  membrane  on  a  stretch,  an  assistant  at  each  side  places  one 
or  two  fingers  on  the  skin  of  the  thigh,  and  draws  the  vulva  outwards 
(Fig.  144).  The  skin  just  beneath  a,  in  front  of  the  anus,  may  also 
be  seized  by  a  tenaculum  and  drawn  doAvnwards.  If  still  the  mucous 
membrane  is  not  sufficiently  on  the  stretch,  from  laxity  of  the  vagina, 
the  posterior  vaginal  wall,  some  distance  above  b,  should  be  seized  by 
long-handled  tenaculum-forceps  and  pushed  upwards.  Incisions  are 
then  made  through  the  mucous  membrane  from  b  to  a,  in  the  median 


840  OPERATIONS    ON    THE    ABDOMEN. 

line  of  the  vagina,  and  from  a  to  c  and  d  through  the  junction  of 
mucous  membrane  and  skin.  Tliese  should  not  be  extended  in  the 
direction  of  o  and  d  further  than  the  lower  extremity  of  the  nymphae 
at  the  utmost.  There  are  then  two  triangular  flaps,  abc  and  abd. 
These  are  to  be  dissected  up  from  the  apex  a  towards  the  base  bc  and 
BD,  the  corner  of  the  mucous  membrane  at  a  being  seized  with  dis- 
secting forceps.  Tlie  dissecting  should  not  be  deeper  than  necessary, 
and  if  it  is  done  with  the  knife  the  surfaces  are  n)ore  ready  to  unite. 
If,  however,  there  is  much  tendency  to  bleed,  scissors  may  be  used. 
The  apices  of  the  flaps  are  then  cut  off  with  scissors,  leaving  an 
upturned  border-  along  bc  and  bd.  When  the  surfaces  are  drawn 
together  these  borders  form  a  slightly  elevated  ridge  towards  the 
vagina,  and  if  there  is  any  failure  of  union  just  along  the  edge  they 
fall  over  and  cover  it. 

"  The  best  material  for  sutures  is  the  silkworm-  or  fishing-gut,  which 
should  be  stout,  of  the  thickness  used  for  salmon  flies.  It  may  be 
stained  with  magenta,  to  render  it  more  easily  visible.  This  has  all 
the  advantage  of  silver  wire,  as  being  non-absorbent,  while  at  the 
same  time,  it  is  easier  to  manipulate,  and  the  exposed  ends  do  not 
cause  discomfort  after  the  operation,  like  those  of  wire.  The  sutures 
are  placed  as  shown  in  the  figure.  The  most  convenient  needle  is  a 
slight!}^  curved  one,  not  too  thick,  mounted  in  a  handle.  This  is 
passed  in,  unthreaded,  rather  close  to  the  edge  of  skin,  brought  out 
on  the  raw  surface,  then  threaded  with  the  end  of  the  suture,  which 
is  so  drawn  through.  By  passing  the  needle  in  the  same  way  on  the 
other  side,  the  other  end  of  the  suture  is  drawn  through.  Another 
mode  is  to  use  a  more  curved  needle,  and  to  bury  the  sutures,  1,  2, 
and  3,  in  the  tissues  throughout  their  whole  course.  If,  however, 
they  are  brought  out  in  the  centre  for  spaces  alternately  short  and 
long  (Fig.  144),  the  surfaces  are  more  easily  brought  into  contact  at 
all  levels  without  undue  tension.  In  passing  sutures  4,  5,  6,  the 
needle  should  be  brought  out  precisely  on  the  margin  along  which 
the  borders  of  mucous  membrane  bc,  bd,  are  turned  up  from  the 
vagina,  not  passing  through  the  mucous  membrane  itself.  The  su- 
tures are  then  tied  in  the  order  of  the  numbers  from  1  to  6,  care  being 
taken  that  the  surfaces  are  brought  just  sufficiently  into  apposition) 
and  that  no  clots  or  blood  are  left  between  them.  The  bleeding,  if 
any  continues,  is  arrested  by  bringing  the  surfaces  together,  and  if 
they  are  properly  united  there  will  be  no  secondary  haemorrhage, 
unless  the  sutures  begin  to  cut  from  excessive  tension.  The  sutures 
may  be  left  in  from  seven  to  ten  days." 

Operation  for  Complete  Rupture  (Fig.  145^.— The  prelimi- 
nary steps  are  taken  as  above.  "  A  point  b  in  the  median  line  of  the 
vagina,  a  sufficient  distance  above  the  apex  of  the  rent  in  the  septum,  is 


RUPTURED    PERINEUM. 


841 


taken,  and  an  incision  through  the  mucous  membrane  is  made  from 
B  to  G,  and  from  g  to  e  and  f  along  the  edges  of  the  septum,  between 
the  rectal  mucous  membrane  and  the  cicatrix.  Incisions  are  also 
made  through  the  skin  from  e  to  c  and  f  to  d,  so  that  the  freshened 
surface  may  extend  somewhat  beyond  the  limits  of  the  cicatrix,  c  or  d 
not  to  be  higher  than  the  lower  extremities  of  the  nympha\  The 
quadrilateral  flap  egbc  is  then  seized  at  e  by  dissecting-forceps,  and 
dissected  up  with  the  knife  from  the  angle  e,  and  afterwards  from  the 
angle  g,  towards  the  base  bc.  While  this  is  done,  the  parts  are  kept 
on  the  stretch  by  an  assistant  drawing  down  the  skin  below  e  with  a 
tenaculum.     The  flap  is  then  cut  away  with  scissors,  except  an  up- 

Fiur.  145 


(Galabin.) 

turned  border,  which  is  left  along  bc.  The  flap  fgbd  is  treated  in  a 
similar  manner.  If,  as  is  usual,  the  ends  of  the  sphincter  at  e  and  f 
have  retracted  from  the  margin  of  the  cicatrix,  it  is  well  to  cut  away 
with  the  scissors  a  narrow  strip  of  rectal  mucous  membrane,  generally 
somewhat  everted,  a  short  distance  from  e  and  f  towards  g,  so  as  to 
bring  the  freshened  surface  to  the  ends  of  the  sphincter. 


842  OPERATIONS  ON  THE  ABDOMEN. 

"  Sutures  of  silkworm-gut  arc  then  applied  in  the  following  manner : 
First,  rectal  sutures,  either  two  or  three,  according  to  tlie  extent  of  the 
rent  in  the  septum,  are  applied.  These  are  designed  to  be  tied  to  the 
rectum,  and  the  ends  left  projecting  through  the  anus.  They  are 
best  applied  with  a  half-curved  needle,  held  in  a  holder.  The  needle 
is  passed  in  a  little  distance  from  the  margin  of  the  rent,  and  brought 
out  almost  at  the  very  edge  of  the  rectal  mucous  membrane,  on  the 
line  GF.  The  needle  is  then  threaded  at  the  other  end  of  the  suture, 
and  that  is  drawn  through  in  the  same  way  from  without  inwards,  on 
the  margin  eg.  Next  two  sutures  at  least  are  passed  completely  round 
through  the  remnant  of  the  septum,  by  means  of  a  curved  needle, 
not  too  large,  mounted  in  a  handle.  This  is  passed  unthreaded,  and 
draws  the  suture  back  with  it  on  withdrawal.  The  first  of  these  (3, 
Fig.  145)  is  passed  in  somewhat  behind  and  below  the  angle  f,  so 
as  to  take  up,  if  possible,  or  at  least  go  quite  close  to,  the  end  of  the 
divided  sphincter,  and  is  brought  out  in  a  similar  position  near  e. 
Thus,  when  tightened,  it  brings  together  the  ends  of  the  sphincter, 
drawing  it  into  a  circle  ;  but  it  often  brings  into  a])position,  not  so 
much  the  freshened  surfaces  above  as  the  unfreshened  rectal  mucous 
membrane.  This  serves  as  a  barrier  to  keep  out  faecal  matter,  while 
the  next  suture  (4,  Fig.  145)  aids  the  rectal  sutures  in  uniting  the 
freshened  surfaces.  The  remaining  sutures  are  passed  as  shown  in 
the  figure  (5-8,  Fig.  145)  by  a  slightly  curved  needle  mounted  in  a 
handle,  in  the  same  way  as  in  the  operation  for  incomplete  rupture 
(Fig.  144).  The  needle,  unthreaded,  is  passed  in  pretty  close  to  the 
edge  CE  or  fd,  is  brought  out  (except  in  the  case  of  suture  5,  Fig.  145) 
on  the  line  where  the  margin  cb  or  db  is  turned  up,  and  draws  one 
end  of  the  suture  back  with  it,  the  other  end  being  afterwards  drawn 
through  in  the  same  way.  The  effect  is,  that  when  the  sutures  are 
lightened,  the  margins  bc,  bd  are  turned  up  into  a  slight  ridge  to- 
wards the  vagina,  and  afterwards  fall  over  and  cover  any  portion  of 
the  vaginal  border  which  does  not  unite  quite  up  to  the  edge.  Suture 
5  (Fig.  145)  may  either  be  buried  throughout,  or  brought  out  for  a 
very  short  space  near  the  median  line  bg. 

"  When  all  the  sutures  are  in  place,  the  sponge*  is  withdrawn  from 
the  rectum,  and  the  rectal  sutures  are  tied  first.  Care  must  be  taken 
to  draw  up  the  whole  of  the  slack  in  the  centre,  and  bring  the  edges 
EG,  fg  perfectly  together.  This  will  approximate  the  ends  of  the 
sphincter  to  a  great  extent,  and  the  approximation  is  completed  by 
tightening  suture  3.  The  remaining  sutures  are  then  tied  in  the 
order  of  the  numbers,  c  ire  being  taken  to  allow  no  clots  or  blood  to 
remain  between,  and  to  tighten  them  just  enough  to  bring  the  sur- 

*  This,  secured  witli  t;ii>e,  is  introduced  into  the  bowel,  to  prevent  tiie  descent  of 
any  faeces  left  by  an  enema. 


RUPTURED    PERINEUM.  843 

faces  in  contact.  The  ends  of  the  rectal  sutures  may  be  left  mode- 
rately long,  to  distinguish  them,  the  rest  cut  pretty  short. 

"  The  perineal  sutures  are  removed  in  seven  days.  The  rectal  sutures 
may  be  left  from  ten  to  fourteen  da3^s  longer,  till  the  perineum  is 
consolidated.  They  are  then  removed  through  a  small  rectal  spec- 
ulum, care  being  taken  not  to  break  down  any  of  the  union  in  passing 
it.  By  this  operation  the  anus  is  generally  much  more  completely 
restored  than  by  the  use  of  quilled  sutures,  or  the  plan  of  making 
deep  lateral  incisions  to  relieve  tension.  If  there  is  much  resistance 
to  bringing  the  surfaces  together,  the  only  thing  required  is  to  use 
more  numerous  sutures,  so  as  to  diminish  the  tension  on  each. 

"  In  some  cases,  by  the  primary  operatior.  after  labor,  only  superficial 
union  is  secured,  and  a  recto-vaginal  fistula  is  left  close  to  the  part 
united.  The  best  plan  is  then  to  cut  through  the  bridge  of  union 
with  scissors  at  the  time  of  the  operation,  and  then  proceed  as  in  the 
case  of  complete  rupture.  This  is  the  only  way  to  secure  a  firm  and 
thick  perineum,  and  is  less  likely  to  fail  than  an  operation  on  the 
fistula  alone." 


PART  V. 

OPERATIONS  ON  THE  LOWER  EXTREMITY. 


CHAPTER  I. 

OPERATIONS  ON  THE  HIP-JOINT. 

AMPUTATION  AT  THE  HIP-JOINT -EXCISION  OP 
THE  HIP-JOINT. 

AMPUTATION  AT  THE  HIP-JOINT. 

This  formidable  operation  has  been  much  simplified  of  late  years 
by  the  most  important  improvement  of  Mr.  Furneaux  Jordan,*  whose 
method  should  replace  all  others  in  every  possible  case.  It  will  be 
described  first  here,  and  a  few  of  the  other  methods,  sufficient  for  all 
practical  purposes,  will  be  given  afterwards. 

Methods. 

I.  Furneaux  Jordan. 
II.  Antero-posterior  Flaps. 

III.  Lateral  Flaps. 

IV.  Modified  Lateral— viz.,  Antero-internal  and  Postero- 
external—Flaps. 

I.  Furneaux  Jordan's  Method  (Fig.  147).— By  amputating 
through  the  thigh  as  low  down  as  i)Ossible,  and  shelling  out  and  dis- 
articulating the  femur,  it  is  now  possible  to  avoid,  in  large  measure, 
those  dangers  which  were  formerly  inseparable  from  the  operation — 
viz. :: 

1..  Shock,,  the  limb  being  removed  much  further  from  the  trunk. 

2..  Haemorrhage-  a.  Abundant  room  i&  afforded  for  compression 
of  the  common  femoral,  and  the  vessels  behind,  h.  The  large  vessels 
can  easily  be  secured  on  the  face  of  the  &tum.p.  c.  The  gluteal  and 
sciatic  arteries  remain  untouched,,  the  haemorrhage-  from  these,  in  the 
older  operations,  being  a  source  of  serious  danger, 

3.  Septic  changes.     By  the  other  methods,  the  copious  discharge  of 

*  Judging  from  a  letter  from  Prof.  Oilier  to  Mr.  Sliuter  (loc.  infra  cit.)  the  former 
surgeon  had  recommended  this  method  as  long  ago  as  1859^  and  performed  such  an 
operatioa  once. 


AMPUTATION    AT   THE    HIP- JOINT.  845 

bloody  serum  from  the  large  wound  *  being  poured  out  close  to  the 
anus  and  genitals,  was  very  liable  to  decompose.  By  this  operation, 
both  the  end  of  the  stump  and  the  wound  on  the  outer  side  can  be 
more  easily  drained  and  kept  aseptic.  In  making  use  of  thi«  amputa- 
tion, especially  for  hip  disease  or  failed  excision,  the  surgeon  should 
not  attempt  too  much  to  secure  primar}^  union. | 

4.  The  stump  is  a  better  one.  It  is  longer,  more  mobile,  and  occa- 
sionally, as  in  amputation  for  acute  periostitis  or  necrosis,  it  is  possible 
to  preserve  much  of  the  periosteum  from  the  upper  half  of  the  femur, 
and  a  cord  X  will  be  left  which  will  render  the  stump  movable. 
Whether  in  any  case  an  artificial  limb  can  be  worn  for  more  than 
about  half  an  hour  at  a  time  is  very  doubtful. 

Methods  of  Controlling  Haemorrhage  during  Amputation 
at  the  Hip. 

1.  Elad'ic  Compression  by  Jordan  Lloyd's  Method  (Fig.  Ii7). — This  may 
be  applied  at  the  junction  of  the  limb  and  trunk,  without  interfering 
with  the  operator,  by  the  following  method  :  When  the  patient  is 
passing  under  the  anaesthetic,  the  limb  is  emptied  of  blood  by  elevation 
and  application  of  Esmarch's  bandages  as  far  up  as  the  tissues  are 
healthy ;  the  patient  is  then  rolled  over  on  to  his  sound  side,  and  a 

*  As  will  be  shown  below,  the  wound  in  a  Furneaux  Jordan  amputation  is  also  a 
large  one,  but  much  more  happily  placed  for  being  drained  and  kept  sweet. 

t  Verneuil  {Paris  Acad,  cle  Med..  1877). 

X  The  committee  of  the  Clinical  Society  appointed  to  examine  Mr.  Shuter's  case  of 
subperiosteal  amputation  at  the  hip-joint  reported  (iT/ans.,  vol.  xvi.  p.  89)  (1)  that, 
though  there  was  a  firm,  resisting  cord  of  considerable  size  in  the  centre,  which  afforded 
the  muscles  a  comnitm  point  of  attachment,  there  was  not  sufficient  evidence  to  enable 
them  to  state  that  this  cord  contained  bone;  (2)  that  the  muscles  were  in  a  high  state 
of  nutrition,  the  patient  not  only  powerfully  flexing,  extending,  abducting,  and  ad- 
ductii'g  his  stump,  but  iieing  aide  to  communicate  all  these  movements  to  the  artificial 
limb. 

Mr.  Shuter  in  his  paper  (/or.  s»/»a  ciV.)  says  that  his  patient  was  able  to  wear  an 
artificial  limb  "for  some  hours  nearly  every  day  for  a  period  of  about  five  months.  I 
then  forbade  his  wearing  it  for  a  time  on  account  of  a  tender  sinus  which  opened  op- 
posite to  the  acetabulum.  In  tiie  notes  of  this  case,  quoted  by  Mr.  Holden  in  his 
obituary  notice  of  Mr.  Sliiiter  {St.  Barthol.  Hosp.  Beports,  vol.  xix.  p.  38),  it  is  stated 
that  "  the  stun)p  was  sufficient  to  enable  the  patient  to  wear  an  artificial  limb  for  a  time, 
but  he  was  oi)liged  to  leave  it  off  on  account  of  its  weiglit."  I  have  now  performed, 
this  amputation  fi\e  time-'."  Four  recovered,  and,  in  one  of  my  three  cases  in  adults 
a  delicate  girl  of  twenty  has  been  able  to  wear  a  very  light  limb,  made  by  Messrs.  Maw 
and  Thompson,  for  three  hours  at  a  time.  In  such  ca.ses  as  these,  where  the  patient  is 
much  reduced  by  long-standing  hip  disease,  and  the  periosteum  is  still  adherent  to  the 
wasted  fennir,  it  is  not,  in  my  opinion,  advisable  to  spend  time  in  stripping  it  off'.  While 
the  shock  of  the  hip-joint  amputation  is  much  lessened  by  this  method,  it  cannot,  of 
course,  be  entirely  removed. 


846  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

piece  of  rul)ljer  bandage  about  2  yards  long,  and  stout  enough  to  re- 
quire decided  exertion  to  stretch  it  out  fully,  is  doubled  and  passed 
between  the  thigh  and  trunk,  its  centre  lying  between  the  anus  and 
tuber  ischii.  A  white  bandage  of  appropriate  size  is  then  laid  over 
the  termination  of  the  external  iliac  artery.  The  ends  of  the  rubber 
bandage  are  now  to  be" firmly  and  steadily  draAvn  in  a  direction  up- 
wards and  outwards^  one  in  front  of  the  groin  and  one  over  the  buttock, 
to  a  point  above  the  centre  of  the  iliac  crest,  sufficient  tightness  being 
employed  to  stop  all  pulsation  in  the  femoral  or  tibials.  The  front 
part  of  the  band  passing  over  the  white  bandage  occludes  the  externa' 
iliac  and  runs  parallel  to  and  above  Poupart's  ligament.  The  posterior 
part  runs  across  the  great  sacro-sciatic  notch  and  controls  the  branches 
of  the  internal  iliac.  If  the  surgeon  is  short  handed,  instead  of  the 
cords  being  held  by  an  assistant,  they  may,  by  means  of  tapes  strongly 
stitched  to  them,  be  thus  secured  :  When  drawn  with  full  tightness  up 
to  the  centre  of  the  iliac  crest,  they  may  be  crossed  over  to  the  opposite 
side  and  tied  firmly  (over  lint)  midway  between  the  crest  and  the  top 
of  the  great  trochanter.  If  a  strong  and  trusty  assistant  is  forthcom- 
ing, it  will  be  better  to  leave  the  bandage  in  his  hands,  but  in  the  case 
of  an  adult  whose  tissues  are  not  wasted,  and  on  a  hot  day,  the  exer- 
tion is  not  a  slight  one,* 

Whether  the  bandage  be  held  or  tied,  especial  care  must  be  taken 
that  it  does  not  slip  from  off  the  external  iliac  nor  over  the  tuber  ischii. 
It  is  a  good  plan  to  pass  the  ends  of  the  india-rubber  band  over  a  slip 
of  wood,  so  as  to  diminish  the  prolonged  pressure  on  the  hands.  To 
prevent  the  bands  sli})ping  down  in  the  way  of  the  surgeon,  two  loops 
of  tape  or  bandage  may  be  thus  employed :  Each,  about  2  feet  in 
length,  is  placed  longitudinally,  before  the  elastic  band  is  applied,  the 
one  over  the  groin,  the  other  well  behind  the  great  trochanter,  the 
centre  of  each  being  where  the  elastic  band  will  go.  When  the  band 
has  been  applied,  these  form  loops  by  means  of  which  the  band  is  kept 
well  out  of  the  operator's  way,  both  at  Poupart's  ligament  and  behind 
the  great  trochanter  (Jordan  Lloyd,  Lancet,  1883,  vol.  i.  p.  897). 

2.  Davijs  Lever  (Fig.  146;. — This  ingenious  instrument,  introduced 
by  Mr.  Davy,  of  the  Westminster  Hospital,  consists  of  a  smoothly 
turned  rod  of  ebony-wood  or  metal,  from  18  to  22  inches  long,  with 
the  rectal  end  enlarged,  bluntly  conical  and  most  carefully  polished 
and  graduated,  and  the  other  forming  the  handle. 

*  As  will  be  seen  from  the  descrii)fion  of  the  operation  below,  this  exertion  is  only 
required  during  shelling  ont  of  the  femur,  a  step  often  simplititd  by  a  previous  excision. 
During  the  circular  ain[)utation  in  the  lower  third  of  the  thigh,  and  the  securing  the 
large  vessels  here,  there  is  abundant  room  to  control  these  by  an  Esniarch's  bandage 
applied  in  the  usual  way. 


AMPUTATION'    AT    THE    HIP-JOINT,  847 

Oil  being  thrown  into  the  bowel,  the  rectal  end  is  introduced  directed 
towards  the  vessel  to  be  compressed,  and  felt  for  over  the  situation  of 
the  artery  through  the  abdominal  wall.  Thus,  if  tlie  right  external  or 
common  iliac  is  to  he  compressed,  the  liandle  is  lowered  and  carried 
over  close  to  the  adductors  on  the  left  side,  so  that  its  end  drops  over 
the  artery  on  the  pelvic  brim  (Fig.  146;. 

Mr.  Davy-!^  claims  for  his  instrument  the  following  advantages  : 

(a)  More  perfect  control  of  l)otli  external  and  internal  iliacs. 

(6)  It  inflicts  a  minimum  amount  of  disturbance  on  the  respiratory 
movements  and  the  circulatory  system. 

(c)  It  is  generally  and  easily  applicable.  A  strictured  rectum  is  the 
sole  obstacle.     [So  also  would  be  a  short  and  tight  meso-rectum.] 

(d)  The  pressure  applied  is  easily  maintained,  while  the  assistant  in 
charge  of  the  lever  is  out  of  the  way  of  the  operator. 

(e)  Its  application  is  quite  safe  in  skilled  hands,  no  injury  having 
ever  resulted,  and  but  little  pain  having  been  suffered. 

(/)  It  is  cheap  and  sinjjjle. 

ig)  It  has  been  successful.  Mr.  Davy,  in  his  paper  above  quoted, 
had  records  of  ten  cases  in  wliich  the  lever  had  been  employed;  the 
total  amount  of  blood  lost  during  the  ten  operations  had  been  under 
18  oz.,  and  there  had  been  80  per  cent,  of  recoveries. 

Disadvantages. — Sim})le  and  ingenious  as  the  above  method  is,  it  is 
be3^ond  doubt  that  it  has  caused  a  fatal  result  from  injury  to  the  peri- 
toneal coat  of  the  rectum.  It  is  now  likely  to  be  replaced  by  the 
Furneaux  Jordan  method.  On  account  of  the  above  risk  I  prefer  to 
meet  the  ha^iiorrhage  either  by  the  above-mentioned  metliod,  or, 
where  this  is  impossible,  by  securing  the  vessels  before  they  are  cut 
(p.  853). 

3.  Compressing  the  common  femoral  or  the  termination  of  the  ex- 
ternal iliac  by  the  fingers  or  hands,  aided,  if  need  be,  by  a  weight.  This 
is  only  possible  in  the  case  of  a  child,  and  the  assistant  thus  employed 
is  liable  to  be  in  the  way  of  the  operator. 

4.  Lister's  Tourniquet. — This  means  of  compressing  tlie  termination 
of  the  abdominal  aorta  is  not  a  light  matter,  apart  from  the  very  grave 
operation  into  which  it  enters.  This  is  owing  to  the  difficulty  of  mak- 
ing sure  of  avoiding  such  important  structures  as  the  duodenum, 
pancreas,  solar  ])lexus,  and  small  intestines,  and  to  its  interference 
with  respiration  and  circulation. 

5.  Commanding  the  main  artery  during  the  operation  either  by  seiz- 
ing a  flap  (Fig.  150)  or  by  securing  the  vessels  before  they  are  divided 
(p.  853.. 

*  Brit.  Med.  Journ.,  1879,  vol.  ii.  p.  685. 


848 


OPERATION'S    OX    THE    LOWER    EXTREMITY. 


Furneaux  Jordan's  Operation.*— The  vessels  in  front  and  be- 
hind being-  connnanded  in  the  manner  given  at  p.  845,t  the  patient's 
pelvis  is  brought  to  the  edge  of  the  table  and  his  bod}'  rolled  a  little 
on  to  the  sound  side,  the  surgeon  standing  usually  to  the  right  of  the 
diseased  limb — Le.,  inside  on  the  left  and  outside  on  the  right  side — 


Fig.  146. 


Fig. 14^ 


Fin.  146— (After  Davy.) 

Fig.  147. — Furneaux  Jordan's  amputation.  Above  is  shown  the  means  of  controlling  hemor- 
rhage described  at  p.  8i'>.  Lower  down  are  seen  the  sinuses  of  an  unhealed  excision,  and  the 
method  of  shelling  out  of  the  femur,  after  a  circular  amputation  has  been  performed,  and  the 
large  vessels  secured. 

draws  up  the  soft  parts  forcibly  with  his  left  hand,  and  makes  a  cir- 
cular incision  through  the  lower  third  of  the  thigh,  using  his  knife  as 
at  p.  100,  the  assistant  who  is  in  charge  of  the  limb  rotating  it  so  as  to 
make  the  tissues  meet  the  knife.     A  circular  cuff-like  flap  of  skin  and 

*  Every  provision  must  l)e  taken  against  sliock.  The  limbs  should  be  bandaged  in 
cotton-woo],  the  body  well  wrapped  up,  the  head  kept  low,  ether  given,  nutrient  injec- 
tions kept  at  hand,  and  subcutaneous  injections  of  brandy  or  ether  given  from  time  to 
time.  In  bad  cases  the  spray  may  be  dispensed  with,  and  the  wound  syringed  from 
time  to  time  with  mercury  perchloride  solution  (1  in  1000). 

f  Before  commencing  the  circular  amputation,  a  little  above  the  knee,  I  have  the 
limb  elevated,  an  Esmarch  bandage  applied  np  to  the  knee,  thetliigh  emptied  of  venous 
blood  by  firm  stroking,  and  a  second  Esmarch  bandage  then  aj)piied  firmly  just  below 
the  trochanters,  and  the  lower  one  removed.  The  india-rubber  band  is  also  (p.  84o) 
l)laced,  lightly,  ready  in  ,s!<M.  The  circular  amputation  is  then  performed,  and  the 
large  vessels  secured.  The  upper  Esmarch  is  next  removed,  and  tlie  india-niliber 
bandage  firmly  tightened  while  the  femur  is  shelled  out  or,  perhaps,  disarticulated. 


AMPUTATION    AT   THE    HIP-JOINT.  849 

fasciffi  is  then  quickly  raised  for  about  2i  inches  *  an  assistant,  who 
stands  opposite  the  surgeon,  giving  much  help  hereby,  seizing  and 
everting  the  cut  edge  of  the  flap,  as  the  surgeon  raises  it.  The  flap 
being  drawn  upwards  out  of  the  way,  the  soft  parts  are  severed  by  one 
or  two  vigorous  circular  sweeps  down  to  the  bone,  and  the  large  vessels 
and  any  others  that  can  be  seen  are  next  secured.  Pressuref  is  now 
made  with  lint  wrung  out  of  carbolic-acid  lotion  on  the  still  oozing 
wound,  and  the  patient  being  now  rolled  well  over  on  to  his  sound  side 
the  surgeon  cuts  along  the  outer  side  of  the  thigh,  starting  from  the 
circular  wound  and  ending  about  midway  between  the  iliac  crest  and 
top  of  the  great  trochanter.  This  incision  goes  straight  down  to  the 
bone  and  runs  into  any  excision  w^ound,  or  sinuses  which  may  exist 
over  the  joint.  The  soft  parts  are  then  rapidly  stripped  off  the  femur, 
partly  with  the  knife,  partly  with  the  finger,  the  only  difficulty  met 
with  being  along  the  linea  aspera.  If  an  excision  has  been  performed, 
the  operation  is  rapidly  completed,  but  if  the  head  and  neck  remain 
intact,  the  final  steps  will  be  rendered  more  difficult,  and  the  joint  must 
be  oj^ened  from  the  outside  b}^  cutting  strongly  on  the  neck  of  the  bone, 
this  being  facilitated  by  the  assistant  moving  the  limb  in  accordance 
with  the  surgeon's  directions,  as  different  parts  require  to  be  put  on  the 
stretch,  rotation  of  the  femur  strongly  outwards,  and  dragging  of  the 
head  away  from  the  acetabulum  being  required  at  the  last. 

Free  drainage  must  be  provided,  for  it  must  be  remembered  that 
the  wound  left  by  this  method  is  a  very  large  one,  though  it  has  the 
advantage  of  being  farther  removed  from  sources  of  sepsis.  Thus, 
especially  if  the  tissues  are  riddled  with  sinuses,  too  much  of  the 
wound  must  not  be  closed,  and,  if  shock  is  present,^  the  surgeon  must 
not  wait  to  insert  many  sutures,  but  trusting  to  firm  bandages  over 
an  aseptic  dressing  get  his  patient  quickly  back  to  bed.  If  disease  of 
the  acetabulum  be  present,  the  surgeon  will,  if  the  patient's  condition 
admit  of  it,  attend  to  this,  the  insertion  of  a  drainage-tube  through 
this  bone  being  specially  required  if  pelvic  suppuration  be  present. 

Amputation  by  Different  Flap  Methods.— The  following  will 

*  The  snrjreon  need  not  tro\il)le  to  raise  a  larger  circular  flap.  As  the  femur  is 
removed,  the  nmscles  lose  their  fixed  point  to  contract  from,  and  are  thus  easily 
covered. 

f  Valuahle  time  should  not  be  wasted  in  trying  to  secure  every  bleeding  point,  either 
now  or  later.     See  the  next  foot-note. 

X  In  some  cases  this  is  so  from  the  beginning  of  the  operation.  This  was  most 
markedly  the  case  in  one  of  the  patients  mentioned  in  the  foot-note,  p.  845,  a  very 
delicate  young  lady  of  twenty-two.  It  was  only  by  not  waiting  to  do  more  than  secure 
the  ftmorals,  mnking  firm  sponge-pressure  on  the  flaps,  tilting  up  the  end  of  the  table 
so  as  to  keep  the  head  low,  inserting  no  sutures,  but  trusting  only  to  firm  bandaging 
over  dry  gauze  dressings,  that  a  fatal  result  was  averted. 

64 


850 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


be  given  here,  it  being  understood  that  in  no  case  can  any  of  them  be 
recommended  if  Furneaux  Jordan's  method  is  available. 

II.  Antero-posterior  Flaps  (Figs.  148-151).  Methods  of 
Guthrie  and  Liston. — The  patient  being  prepared  against  shock 
(l).  848),  and  tlie  main  vessels  secured  by  one  of  the  methods  already 
given,  the  limb  being  brought  over  the  table  and  supported  in  the 
semi-flexed  position  by  an  assistant,  while  the  opposite  limb  is  se- 
cured over  the  table  by  a  bandage,  the  surgeon  standing  outside  the 
left  and  inside  the  right  limb,  raises  the  tissues  in  front  of  Scarpa's  tri- 
angle with  his  left  hand,  enters  his  knife  (e.g.,  on  the  leftside)  midway 
between  the  anterior  superior  spine  and  the  top  of  the  great  trochanter, 
and  sends  it  across  the  liml)  so  that  it  emerges  close  to  the  tuberosity 


F:g.  148.^ 


Fig.  149. 


(Fergusson.) 


of  the  ischium.  In  traversing  the  limb  the  knife  should  pass  as  close 
to  the  capsule  as  possible,  so  as — (1)  to  get  behind  the  large  vessels; 
and  (2)  to  facilitate  the  opening  of  the  capsule  later  on.  As  the  knife 
emerges,  the  surgeon  will,  of  course,  be  careful  of  the  scrotum"  and 
the  opposite  thigh,  and  at  this  moment  the  point  should  be  well  de- 
pressed, so  as  to  include  all  the  tissues  possible  in  the  anterior  flap. 
With  a  rapid,  sawing  movement  a  broad  flap  is  cut,  5  inches  long,  an 
assistant  thrusting  his  fingers  into  the  wound  as  it  is  made,  and  fol- 
lowing the  back  of  the  knife,  to  secure  the  large  vessels  (Fig.  149). 
As  he  then  draws  up  the  anterior  flap,  the  capsule  is  exposed,  covered 
with  more  or  less  soft  parts,  according  to  the  skill  with  which  the 
knife  has  been  first  inserted ;  the  assistant  in  charge  of  the  limb  at 


The  knife  represented  here  is  needlessly  long. 


AMPUTATION    AT    THE    HIP- JOINT. 


851 


this  moment  extending,  depressing,  and  rotating  out  the  femur,  so 
as  to  put  the  ca})sule  on  the  stretch,  the  surgeon  forcibly  draws  the 
knife  across  the  capsule,  opens  it  freely,  and  divides  the  ligamentum 
teres  (Figs.  148,151). 

The  limb  being  now  slightly  flexed,  adducted,  and  pulled  awa}^ 
from  the  body,  the  surgeon  severs  the  parts  attached  to  the  great  tro- 
chanter, and  the  outer  aspect  of  the  limb,  and  passing  his  knife  behind 
the  bone,  cuts  a  posterior  flap  about  4  inches  long.  The  assistant  in 
charge  of  the  limb  will  facilitate  this  step,  and  further  the  dislocation 
of  the  femur,  if  he  press  the  thigh  upwards  and  forwards  with  one 
hand  placed  at  the  back.  A  large  sponge,  wrung  out  of  1  in  20  car- 
bolic acid,  is  at  once  pressed  against  the  posterior  flap  while  the  femo- 


FiG.  150. 


Fig. 151. 


-Si 


ral  vessels*  are  secured,  or,  if  tliese  are  well  in  hand,  those  in  the 
hinder  flap  are  taken  first.  The  glut^cal  will  be  found  on  the  glutseal 
muscles,  the  sciatic  with  the  nerve  nearer  the  posterior  margin  of  the 
flap,  and  the  circumflex  and  obturator  closer  to  the  acetabulum. 

If  the  patient's  condition  admits  of  it,  any  sinuses  are  now  laid 
open  or  scraped  out,  the  acetabulum  examined,  and,  if  perforated, 
drained.  If  the  amputation  has  been  for  growths,  any  outlying 
masses  are  looked  for  and  removed.  Any  nerves  or  muscles  which 
need  it  are  now  trimmed  short,  a  large  drainage  tube  inserted,  and  the 
flaps  carefully  united. f 

*  Of  these  the  femoral  lies  superficially,  the  profunda  more  deeply,  in  the  anterior 
flap:  they  are  shown  mnch  too  close  to  eacli  other  in  Fig.  150. 

t  If  the  patient's  condition  is  one  of  grave  shock,  the  head  should  be  lowered  and 
no  time  lost  in  putting  in  sutures,  any  oozing  being  stopped  by  firm  spica-bandaging 
over  thick  dressings  of  aseptic  gauze.  The  lower  end  of  the  bed  should  be  kept  raised, 
and  brandy  given  subcutanebusly  and  per  rectum  (foot-note,  p.  849). 


852  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

Advantages  of  this  methorl.     Chief  of  these  is  its  rapidity. 
Disadvantages. 

1.  The  hfemorrhage  which  takes  place  from  the  vessels  from  the 
posterior  flap  may  be  considerable. 

2.  The  large  amount  of  sero-sanguineous  oozing  which  takes  i)lace 
from  so  many  large  muscles  cut  obliquely. 

3.  The  fact  that,  in  an  adult,  it  requires  a  special  long  knife,  not 
always  found  in  an  ordinary  collection  of  instruments. 

Diffiadties. 

1.  Not  passing  the  knife  deeply  enough,  and  thus  not  exposing  the 
capsule. 

2.  Passing  the  knife  too  deeply,  and  hitching  its  point  on  the  bone. 

3.  Getting  the  knife  stopped  in  jiassing  it  behind  the  head  of  the 
femur. 

4.  Fracture  of  the  femur. 

Guthrie's  Method  by  Antero-Posterior  Flaps. — Antero-pos- 
terior  flaps  are  again  made  use  of,  but  here  they  are  made  from  without 
inwards,  and  thus  can  easily  be  rendered  less  bulky.  A  small  knife — 
i.e.,  one  4  inches  long — suffices. 

The  preparatory  steps  being  taken  as  before,  the  surgeon,  standing 
on  the  right  side  of  either  limb,  marks  out  his  anterior  flap,  about  5 
inches  long,  by  an  incision,  starting  (on  the  left  limb)  from  just  above 
the  great  trochanter,  passing  across  the  thigh  with  a  broadly  curved 
convexity,  and  ending  just  below  the  tuber  ischii.  A  posterior  flap  is 
then  marked  out  by  carrying  the  knife  in  a  similar  manner  across  the 
back  of  the  limb  between  the  same  points,  the  limb  being  raised  and 
the  surgeon  stooping  somewhat.  This  flap  should  be  about  two-thirds 
the  length  of  the  first.  Both  consist  of  skin  and  fascias.  The  flaps 
being  held  out  of  the  way,  the  muscles  first  on  the  front  and  then  on 
the  back  are  next  cut  obliquely  from  below  upwards,  the  femoral 
vessels,  both  superficial  and  deep,  being  secured  as  soon  as  they  are 
exposed,  and  before  they  are  cut,  either  by  underrunning  them  with 
an  aneurism-needle  loaded  with  silk,  or  by  dividing  them  between  two 
pairs  of  torsion-forceps.  The  capsule  being  exposed,  disarticulation 
is  performed  as  before. 

III.  Lateral  Flaps. — The  methods  of  Larrey  and  Lisfranc  need 
not  be  more  than  alluded  to  here.  In  both,  the  flaps  were  cut  by 
transfixion,  and  were  about  4  inches  long.  Larrey  tied  the  common 
femoral  as  a  preliminary  step.  Flaps  made  by  either  method  are  so 
bulky  as  not  to  be  recommended. 

If  the  surgeon  wishes  to  use  lateral  flaps,  as  in  a  case  involved  by 
growth  in  front,  he  may  make  them,  thus,  from  without  inwards. 
Standing  on  the  right  side  of  either  limb,  he,  e.g.,  in  the  case  of  the 
right  limb,  marks  out  an  inner  flap  by  means  of  an  incision  starting 


AMPUTATION    AT   THE    HIP-JOINT. 


853 


from  below  the  tuber  ischii,  carried  downwards  along  the  inner  aspect 
of  the  thigh  for  about  4  inches,  and  then  curving  uj^ wards  to  the  centre 
of  the  groin  and  ending,  a  little  below  Poupart's  ligament,  to  the  outer 
side  of  the  femoral  vessels ;  next,  without  taking  off  his  knife,  he  then 
marks  out  an  outer  flap  b}'-  cutting  between  the  same  points,  but  in 
the  reversed  direction.  This  incision,  as  it  passes  dowaiwards,  out- 
wards, and  backwards,  should  leave  the  front  of  the  limb  about  a 
hand's-breadth  below  the  great  trochanter.  The  flaps  being  dissected 
up,  the  soft  parts  are  cut  through  from  without  inwards,  the  femoral 
vessels  being  secured  before  they  are  cut,  and  disarticulation  performed 
last. 

IV.  Antero-internal  and  Postero-external  Flaps  (Fig.  152). 
— This  is  a  modification  of  the  L^-^t  metliod,  and  may  be  useful  in 
cases  of  growth  extending  high  up,  where  it  is  impossible  to  perform 

Fig.  152. 


a  Furneaux  Jordan's  amputation.  Some  such  flaps  as  the  above  may 
be  the  only  ones  obtainable.  They  may  be  made  as  follows  :  The 
precautions  as  to  shock  given  at  p.  848  having  been  taken,  the  patient's 
pelvis  having  been  brought  well  down  to  the  edge  of  the  table,  and  the 
opposite  limb  being  held  aside,  but  not  tied,  the  surgeon,  standing  to 
the  right  of  either  limb,  reaches  somewhat  over  and  marks  out  (in  the 
case  of  the  right  limb)  an  antero-internal  flap,  by  cutting  from  a  point 
close  to  the  tuber  ischii  to  one  a  little  below  and  internal  to  the  anterior 
superior  iliac  spine.  The  skin  and  fascite  being  dissected  up,  the 
muscles  are  cut  through  till  the  femoral  vessels    are  reached  and 


854  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

secured.  Large  carbolized  sponges  are  noAV  pressed  into  this  wound, 
and,  the  patient  being  rolled  a  little  over,  a  postero-external  flap  is 
marked  out  and  dissected  up  from  the  gluteal  region,  passing  between 
the  above  points,  but  in  the  reverse  order.  The  gluteal  vessels  are 
next  cut  through,  the  chief  vessels  being  secured  by  either  torsion  or 
Spencer  Wells's  forceps ;  the  capsule  is  then  opened,  the  round  liga- 
ment severed,  and  the  limb  removed. 

EXCISION  OF  THE  HIP. 

Indications. — A.  Disease.     B.  Injury,  especially  gunshot. 

A.  Disease. — The  value  of  this  operation  still  remains  unsettled. 
In  spite  of  all  tlie  work  done  in  this  direction,  there  is  no  other  oper- 
ation of  equal  importance  on  which  there  is  still  such  extreme  difference 
of  opinion  on  the  chief  questions  which  have  been  raised  again  and 
again — viz.,  Does  it  save  life?  Does  it  shorten  treatment? 
Is  the  limb  a  better  one  ? 

Thus,  to  take  two  of  the  most  recent  writers  on  hip  disease  and  the 
subject  of  excision,  Mr.  Howard  Marsh,*  with  his  experience  gained 
from  Ormond  Street  and  the  Alexandra  Hospital  for  Hip  Disease  in 
Childhood,  and  Mr.  G.  A.  Wright,t  of  Manchester  and  the  Pendlebury 
Hospital  for  Sick  Children.  Mr.  Marsh  is  strongly  against  excision, 
for  these  reasons.  He  considers  the  results  obtained  by  continued 
rest  to  be  such  as  to  render  excision  totally  uncalled  for.  Thus,  con- 
tinued rest  gives  a  mortality  of  only  5  per  cent.,  70  per  cent,  of  the 
cases  thus  treated  recovering  with  only  slight  lameness  and  loss  of 
movement.  Even  when  suppuration  has  occurred,  the  mortality  is 
only  6  or  8  per  cent.  Again,  at  p.  309,  Mr.  Marsh  writes :  "  The  esti- 
mate that  I  have  been  led  to  form  is,  (a)  that,  in  the  early  stage  of 
the  disease,  although  matter  is  developed,  the  operation  is  as  unjus- 
tifiable as  it  is  to  remove  a  testis,  an  eye,  or  a  tooth  for  incipient  but 
still  curable  disease;  {b)  that  the  operation  is  generally  uncalled  for, 
even  when  sinuses  have  formed ;  (c)  that  if  hip  disease  has  been 
allowed  to  reach  the  stage  in  which  the  bones  have  become  extensively 
carious,  in  which  matter  has  burrowed  widely,  and  in  which  the 
general  health  has  become  seriously  affected,  excision  will  be  of  very 
doubtful  benefit.  The  operation  will  be  fatal  in  at  least  10  per  cent, 
of  the  cases,  while  in  another  20  or  25  per  cent,  it  will  be  followed  by 
no  improvement  in  the  patient's  condition." 

On  the  other  hand,  my  old  friend,  G.  A.  Wright,  speaking  from  the 
very  large  experience  of  over  a  hundred  cases  of  excision,  of  which 
only  three,  at  most,  died  of  the  direct  results  of  the  operation,  strongly 
urges  that  the  hip  should  be  excised  "  as  soon  as  there  is  any  evidence 

*  Diseases  of  the  Joints,  p.  317.  f  ^'P  Disease  in  Childhood,  p.  93, 


EXCISION    OF   THE    HIR,  855 

of  external  abscess  ....  and  still  better  results  would,  I  believe,  be 
obtained  by  operating  before  the  pus  has  escaped  from  the  articulation. 
The  operation  is  discredited  because  it  is  put  off  until  disease  is  so  far 
advanced  that  no  treatment  can  have  more  than  a  fraction  of  good 
results,  while  timely  excision  cuts  short  the  disease,  saves  pain,  lessens 
the  time  of  treatment,  and  gives  a  better  limb."  And  again,  at  p.  97 
of  his  book,  Mr.  Wright  says  :  "  While  fully  aware  that  abscesses  dis- 
appear and  tuberculous  lesions  cicatrize  under  favorable  circumstances, 
I  think  that,  in  the  case  of  the  hip,  delay  is  unwise  amongst  the  hospital 
class,  with  whom  it  is  as  yet  impossible  to  deal  on  the  same  lines  as 
with  the  well-to-do.  In  almost  every  instance  I  have  found  much 
more  extensive  disease  than  might  be  expected  from  the  external  evi- 
dence, unless  the  pathology  of  the  affection  is  borne  in  mind,  and  I 
believe  that,  once  this  chronic  osteo-myelitis  is  established,  nothing 
short  of  excision  can,  in  hospital  cases,  prevent  tlie  ultimate  progress  of 
the  disease  to  abscess,  and  too  often  to  gradual  exhaustion  of  the  patient 
by  pain  and  discharge.  Nature,  of  course,  in  many  cases  will,  unaided, 
get  rid  of  the  dead  bone  by  slow  and  tedious  processes,  but  the  num- 
ber of  children  who  can  survive  the  process  of  ehniination  is  very 
small,  while  the  mortality  after  early  excision  is  not  great,  and  the 
failures  are  mainly  in  those  instances  where  the  operation  has  been 
put  off  till  too  late.  Where  actual  necrosis,  or  caries  of  the  head  of 
the  femur,  with  destruction  of  bone  and  cartilage,  and  often  sequestra 
of  varying  size  in  the  acetabulum,  or  at  least  caries  of  it  are  known  to 
exist,  I  think  few  advocates  of  non-operative  treatment  will  be  found." 
With  reference  to  so  wide  a  divergence  of  opinion  between  two  author- 
ities on  the  subject,  it  may  be  pointed  out  that  Mr.  H.  Marsh  has 
worked  under  conditions  more  favorable  than  those  which  fall  to  the 
lot  of  most  hospital  surgeons.  Thus,  at  the  Alexandra  Hospital,  cases 
are  kept  under  treatment  as  long  as  rest  and  extension  are  required ; 
if  an  operation  is  called  for,  the  case  is  transferred  elsewhere.  While 
every  one  must  admire  Mr.  Marsh's  success,  it  is  clear  that  the  condi- 
tions under  which  it  has  been  gained  must,  as  yet,  stand  alone. 

My  own  opinion  as  to  the  advisability  of  excision  in  the  ordinary 
hip  disease  of  liospital  children  is,  that  it  should  be  resorted  to  by 
surgeons  chiefly  when  suppuration  is  present  and  has  resisted  a  due 
trial  of  rest,  and  antiseptic  incision  and  drainage,  this  latter  step  giving 
an  opportunity,  though  a  limited  one,  of  investigating  the  amount  of 
disease  present.  But  while  I  should  thus  advocate  the  performance 
of  the  operation  in  the  second  stage,  I  think  that  sufficient  importance 
has  not  l:)een  attached  to  the  fact  that  disease  of  the  hip-joint  is,  unless 
not  only  seen  but  treated  in  the  first  stage,  severe  and  progressive,  and, 
perse,  likely  to  end  fatally;  if  this  be  so,  excision  must  not  be  too 
much  reproached  with  failure. 


856  OPERATIONS    OX   THE    LOWER    EXTREMITY. 

The  conditions  which  usually  accompany  obstinate  suppuration,  and 
which  thus  call  for  excision,  are  those  six  given  by  the  Clinical  Society's 
Committee  on  excision  of  the  hip-joint — viz. : 

i.  "  Necrosis,  and  separation  of  the  entire  head  of  the  femur,  and  its 
conversion  into  a  loose  sequestrum."* 

ii.  "  The  presence  of  firm  sequestra  either  in  the  head  or  neck  of  the 
femur,  or  in  the  acetabulum."  This  question  is  a  most  important  one, 
for  as  Mr.  Marsh  (p.  318)  writes,  "  much  difference  of  opinion  exists 
as  to  the  frequency  with  which  hard  sequestra  of  any  material  size  are 
present  in  suppurative  hip  disease."  He  himself  thinks  that  when 
present  sequestra  usually  consist  of  porous,  friable  bone.  Their 
structure  is  such  that,  should  excision  not  be  performed,  they  will 
crumble  away  and  disappear,  and  will  not  prevent  repair.f  A  dis- 
tinctly different  opinion  is  held  by  Mr.  Wright  (loc.  supra  cit,  p.  118)  : 
"  here  opening  of  abscesses,  and,  still  less,  expectant  treatment,  can 
hardly  be  considered  a  satisfactory  mode  of  getting  rid  of  sequestra, 
yet  in  no  less  than  in  39  (out  of  100)  w^ere  there  actual  loose  sequestra, 
while  in  many  others  there  were  patches  of  bone  which  was  practically 
dead  though  not  loose.  The  possibility  of  removing  sequestra  with- 
out a  formal  excision  is  worth  trying  in  some  cases,  but  it  is  often 
impossible  to  discover  the  presence  of  the  sequestra  until  the  end  of 
the  bone  has  been  removed,  or  to  extract  them  if  found.  Moreover, 
even  after  the  removal  of  sequestra,  others  may  exist  and  not  be  found, 
and  in  other  instances  the  disease  progresses  in  the  surrounding  bone 
and  necessitates  subsequent  excision.  There  are  often,  too,  other  foci 
of  disease  in  the  medulla,  which  are  as  great  bars  to  recovery  as  the 
sequestra  themselves." 

iii.  "  Extensive  caries  of  the  femur,  or  the  pelvis,  leading  to  prolonged 
suppuration  and  the  formation  of  sinuses." 

iv.  "  Intra-pelvic  abscess  following  disease  of  the  acetabulum." 

With  reference  to  these  conclusions,  I  should  doubt  myself  whether 
excision  can  be  often  justifiable,  especially  in  the  latter.  Even  if  it 
gave  the  desired  drainage  the  patient's  condition  with  disease  of  the 
acetabulum  is  not  one  usually  to  give  the  required  repair  after  excision. 

*  Mr.  Marsh  {lor.  supra  cit,  Fig.  50,  p.  383)  thitiks  that  these  cases  are  not  rare. 
Mr.  Hilton  (Rent  avd  Pain,  Fig.  63,  p.  341)  shows  a  similar  specimen.  I  sliould  liave 
tlioiight  the  condition  a  very  iincoramon  one. 

f  "This  seems  to  be  proved  by  the  fact  that  in  numerous  cases  in  which  profuse  sup- 
puration has  been  going  on,  so  that  tliere  can  be  no  reasonable  doubt  that  extensive 
bone  disease  has  been  present,  all  the  sinuses  will  close,  although  either  no  bone  has 
worked  out  or  been  extracted.  In  these  instances  we  must  conclude  either  that  no  se- 
questra were  present,  and  in  that  case  it  would  appear  that  sequestra  are  not  so  common 
as  some  believe ;  or  that  they  often  crumble  away  and  are  discharged,  so  that  operative 
interference  is  by  no  means  essential  for  their  removal"  (Marsh,  loc.  supra  cit.,  p.  319). 


EXCISION    OF    THE    HIP.  857 

"  Extensive  caries  "  of  the  pelvis  certainly,  and  in  many  cases  of  the 
femur,  will  require  amputation,  especially  after  childhood. 

V.  "  Extensive  and  old-standing  synovial  disease  and  ulceration  of 
the  articular  cartilages,  with  persistent  suppuration."  This  condition 
is  rarely  met  with  in  the  hip-joint,  where  the  disease,  as  usually  met 
with,  starts  not  in  the  synovial  membrane,  as  in  the  knee-joint,  but  as 
a  chronic  osteo-myelitis  in  the  neighborhood  of  the  epiphyses,  espe- 
cially the  upper  one. 

vi.  "  Displacement  of  the  head  of  the  femur  on  the  dorsum  ilii,  with 
chronic  sinuses  and  deformity." 

This  condition  will  probably  be  more  rarely  met  with,  nowadays, 
as  earlier  facilities  for  treating  hip  disease  arise.  I  happen  to  have 
performed  excision  five  times  for  such  cases ;  of  these  four  recovered 
with  sound  and  useful  limbs,*  but  in  one,  a  lad  of  eighteen,  in  which 
the  sinuses  had  closed  some  years  before  the  operation,  I  should  now 
pi'efer  to  improve  the  condition  of  the  limb  by  a  Gant's  osteotomy  and 
division  of  the  contracted  sartorius,  tensor  vaginse,  and  adductor  longus. 
These  patients  seem  to  me  to  bear  excision  well,  this  being  probably 
due  to  their  having  good  vitality,  as  shown  by  their  survival,  and  the 
amount  of  repair.  Further,  in  running  successfully  the  gauntlet  of 
the  disease,  they  have  escaped  the  dangers  of  lardaceous  and  general 
tubercular  trouble.  The  surgeon  must  here  be  prepared  for  a  good 
deal  of  trouble  in  dislodging  the  displaced  head,  after  sawing  through 
its  neck,  owing  to  its  being  firmly  matted  down  by  old  adhesions. 

The  Condition  of  the  Limb.  Is  this  a  better  one  after  Ex- 
cision or  after  a  Cure  by  Rest  ? 

Here,  again,  the  divergence  of  opinion  is  marked  and  puzzling.  Mr. 
Marsh  (loc.  supra  cit,  p.  308)  is  of  opinion  that  "^  the  limb  after  excision 
of  either  the  hip  or  the  knee  is  usually  very  inferior  to  the  average 
limb  that  is  obtained  after  recovery  has  followed  the  treatment  by 
rest."  Mr.  Holmes  {Syst.  of  Surg.,  vol.  iii.  p.  757,  1883)  thinks  that, 
while  recovery  after  excision  of  tlie  hip-joint  is  very  complete,  as  far 
as  the  movements  of  the  limb  are  concerned,  "  the  shortening  is  gen- 
erally greater  than  after  the  spontaneous  cure,  and  the  limb  is  less 
firm,  and,  on  the  average,  less  useful."  The  Clinical  Society's  Com- 
mittee reported  on  this  subject  that,  after  excision,  "  movement  is  more 
frequently  present,  and  also  more  extensive,  but  that  patients  often 
walk  more  insecurely  and  with  a  considerable  limp,  while  the  limb 
after  treatment  by  rest  and  extension,  though  frequently  more  or  less 
fixed,  is  more  firm  and  useful  for  the  purposes  of  progression."  While 
feeling  assured  that  the  resulting  usefulness  in  some  cases  treated 
by  excision  far  surpasses  the  best  results  obtained  by  rest,  I  consider 

*  The  fifth  has  only  just  been  operated  on. 


858  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

that  the  average  result  obtained  by  rest  is  superior  to  that  following 
excision,  and  that  this  is  increasingly  marked  after  childhood,  the 
limb,  in  adolescents  recovering  after  excision,  being  very  often  flail- 
like and  useless. 

On  the  other  hand,  Mr.  Wright,  whose  large  experience  on  this  sub- 
ject has  already  been  referred  to,  has  come  to  the  conclusion  (loc.  supra 
cit,  p.  126j  that  "  excision  gives  a  better  limb  than  the  average  result 
obtained  without  operation ;  "  and  again  (p.  114) :  "  In  my  own  expe- 
rience, useless,  flail-like  joints  are  exceedingly  rare,  and  limited  to  those 
cases  where  the  excision  was  performed  in  very  late  stages  of  the  disease ; 
the  powerless  condition  is,  I  take  it,  the  result  of  the  disease,  not  of 
the  operation."  With  regard  to  the  two  conditions  which  chiefly 
interfere  with  the  usefulness  of  the  limb  after  hip-excision — viz.,  a 
flail  like  state,  and  shortening,  Mr.  Wright's  opinion  on  the  former  has 
already  been  given.  With  regard  to  the  latter,  he  considers  (p.  108), 
that,  "  though  some  shortening  must  necessarily  result,  this  arises 
mainly  from  the  weight  being  borne  upon  the  limb  prematurely. 
....  Growth  in  length  of  the  femur  takes  place  almost  entirely  at 
its  lower  epiphysial  line,  hence  the  loss  of  length  or  true  shortening 
is  only  the  distance  from  the  line  of  section  to  the  top  of  the  head, 
coupled  with  such  arrest  of  growth  as  may  result  from  impaired  nutri- 
tion, this  last  being,  of  course,  a  very  inconstant  quantity."* 

Conditions  of  Success  in  Excision  of  the  Hip. — Amongst 
these  are : 

1.  Age.  I  consider  the  best  six  to  fourteen.  After  eighteen  excision 
should  rarely  be  performed,  Furneaux  -Jordan's  amputation  taking  its 
place.  Mr.  Wright  (p.  12(3;  thinks  that  after  fifteen  excision  should 
be  rejected  in  favor  of  amputation. 

2.  Absence  of  lardaceous  disease.  I  cannot  agree  with  the  conclusion 
of  the  Clinical  Society's  Committee  {loc.  supra  clt.,  p.  233)  that  excision 
is  called  for,  "  when,  in  a  case  of  suppuration,  enlargement  of  the  liver 
and  albuminuria,  indicating  the  presence  of  degeneration  of  the  viscera, 
is  detected."  Excision  should  be  performed,  in  my  opinion,  before 
only  the  appearance  of  lardaceous  disease.  When  there  is  evidence 
of  this  condition  having  set  in,  especially  in  the  kidneys  or  intestine, 
amputation  is  to  be  preferred. 

3.  Absence  of  advancing  mischief  in  other  joints,  or  of  tubercular 
lesions  in  the  viscera — e.g.,  the  lung. 

4.  The  disease  must  be  removed  as  entirely  as  possible.     Thus,  in 

*  On  this  matter  Mr.  Wright  quotes  Prof.  Ollier's  (Rev.  de  Chir.,  1881 ;  Annah  of 
Surgery,  January,  1886)  estimate  that,  np  to  five  years  of  age,  the  growth  of  the  femur 
takes  place  about  equally  at  its  two  ends ;  that,  after  five,  the  rate  of  growth  of  the  lower 
end  increases  rapidly  till  it  becomes  three  times  that  of  the  upper. 


EXCISION    OF    THE    HIP.  S59 

the  femur  at  least,  the  section  must  pass  below  all  foci  of  disease. 
All  sinuses  should  also  be  scraped  out. 

5.  Adequate  drainage. 

6.  Careful  after-treatment,  the  wound  being  kept  aseptic. 

7.  The  patient  must  not  be  kept  too  long  on  his  back  in  hospital  air. 
B.  Gunshot  Injuries. 

Excision  of  the  Hip-joint  for  Gunshot  Injuries,  contrasted 
with  Conservative  Treatment,  and  Amputation  at  the  Hip- 
joint, — For  the  sake  of  convenience  it  will  be  well  to  take  the  above 
three  plans  of  treatment  of  gunshot  injuries  of  the  hip  together. 
As  before,  I  shall  avail  myself  of  the  laborious  researches  and  the 
unrivalled  authority  on  this  subject  of  Dr.  Otis.  He  writes*  that 
the  evidence  collected  during  the  American  war  shows  that  "  of  the 
cases  of  undoubted  intra-capsular  shot-fracture  of  the  hip  treated  by 
conservation,  98.8  per  cent,  had  a  fatal  termination,  that  in  sixtv-six 
cases  treated  by  excision,  the  fatality  was  90.9  per  cent.,  and  that  in 
sixty -six  cases  treated  b\'  exarticulation,  it  was  83.3  per  cent. ;  but 
from  these  results  it  should  not  be  concluded  that  operative  interfer- 
ence was  always  indicated,  and  that  amputation  was  preferable  to 
excision.  On  p.  121  of  Circular  No.  2,  I  have  alread}^  pointed  out  that 
the  question  as  to  the  most  eligible  treatment  of  shot  injuries  of  the 
hip-joint  is  not  susceptible  of  a  purely  arithmetical  solution,  and  that 
the  variety  of  the  conditions  under  which  the  patients  are  placed,  the 
diversity  in  the  extent  of  their  injuries,  and  the  inevitable  imperfec- 
tion of  all  surgical  records,  forbid  any  such  rigorous  comparison.  No 
less  than  nine  of  the  sixty-six  cases  of  excision  were  complicated  with 
such  lesions  of  the  pelvic  walls  and  viscera  as  made  any  operative 
interference  useless;  among  the  sixt3'-six  coxo  femoral  amputations, 
probably  all  successful  cases  have  been  recorded,  while  some  fatal 
cases  may  remain  unpublished,  and  in  the  304  cases  treated  by  con- 
servation, the  correctness  of  the  diagnosis  may  be  questioned  in  many 
instances.  The  character  of  the  injury  must  determine  the  choice  of 
treatment;  but  the  general  rules  regarding  shot  wounds  of  the  hip- 
joint  laid  down  in  Circular  2  are  uncontroverted :  that  expectant 
treatment  is  to  be  condemned  in  all  cases  in  which  the  diagnosis  of 
direct  injury  to  the  articulation  can  be  clearly  establislied,''  that 
"  primary  excisions  of  the  head  or  upper  extremity  of  the  femur 
should  be  performed  in  all  uncomplicated  cases  of  shot-fracture  of  the 
head  or  neck  ;"  that  "  intermediary  excisions  are  indicated  in  similar 
cases  where  the  diagnosis  is  not  made  out  till  late ;"  that ''  secondary 
excisions  are  demanded  by  caries  of  the  head  of  the  femur  or  second- 
ary involvement  of  the  joint ;"  that  amfjutation  should  be  performed — 

*  Med.  and  Surg.  History  of  the  War  of  the  Rebellion,  pt.  iii.  p.  I  Go. 


860  OPERATIONS    OX    THE    LOWER    EXTREMITY. 

"  1.  When  the  thigh  is  torn  off,  or  the  upper  extremity  of  the  femur 
comminuted  with  great  laceration  of  the  soft  parts,  in  such  proximity 
to  the  trunk  that  amputation  in  continuity  is  impracticahle.  2.  When 
a  fracture  of  the  head,  neck,  or  trochanters  of  the  femur  is  complicated 
with  a  wound  of  the  femoral  vessels.  3.  When  a  gunshot  fracture 
involving  the  hip-joint  is  complicated  by  a  severe  compound  fracture 
of  the  limb  lower  down,  or  by  a  wound  of  the  knee-joint." 

It  is  possible  that  Dr.  Otis's  opinion  as  to  the  uselessness  of  expectant 
treatment  in  gunshot  injuries  of  the  hip-joint  will  need  alteration  in 
the  future — /.c,  Prof.  Langenbeck,*from  his  experience  in  the  Franco- 
German  war,  considered  that  the  expectant  treatment  gave  a  larger 
proportion  of  recoveries  than  excision,  and  still  more  than  amputa- 
tion, and  advised  that  the  expectant  method  should  always  be  resorted 
to  save  when  disarticuhition  is  rendered  inevitable  by  the  destruction 
and  shattering  of  the  limb.  Sir  T.  Longmoref  thinks  that  this  ques- 
tion must  be  held  ta  be  "  still  sub  judice,  and  surgeons  must  wait  for 
still  more  extended  experience,  under  modern  improved  methods  of 
treatment,  before  any  rule  can  be  accepted  as  having  yet  been  estab- 
lished on  this  grave  question." 

Examining  into  the  dates  at  which  the  excisions  of  the  hip  were 
performed,  Dr.  Otis  ( loc.  supra  cit.,  p.  126)  gives  the  mortality  rate  as 
93  per  cent,  for  the  primary,  96.6  per  cent,  for  the  intermediary,  and 
63.4  per  cent.,  for  the  secondary  operations.  Thus,  "  the  excisions  and 
amputations  practiced  during  the  intermediary  or  inflammatory  stage 
are  by  far  the  most  dangerous,  and  should  never  be  performed  except 
as  compulsory  operations." 

As  to  the  dates  of  the  exarticulations  of  the  254  cases,  there  were  82 
primary,  with  75  deaths  (91.4  per  cent,  mortality) ;  55  intermediary, 
with  52  deaths  (94.5  per  cent.) ;  40  secondary,  with  33  deaths  (82.5  per 
cent.) ;  reamputations,  with  4  deaths-  (36.3- per  cent.).  Dr.  Otis  shows 
from  these  statistics  that  "  intermediary  operations  offer  the  least 
chance  of  recovery,  that  the  results  of  primary  operations  are  more 
favorable;  that  secondary  exarticulations  give  one  recovery  in  twelve 
cases ;  and  that  of  the  instances  of  re-amputation  one  in  about  three 

proves  successful Unless  the  nature  of  the  injury  is  such  that 

the  operation  can  be  delayed  till  the  secondary  period,  it  is  better  that 
it  should  be  done  at  once,  although  it  would  appear  that  the  dire  results 
of  amputations  at  the  hip  performed  during  the  Schleswig-Holstein 
war  of  1864,  the  Austro-Russian  war  of  1866,  and  the  Franco-Prussian 
war  of  1870-71,  have  had  a  tendency  to  raise  doubts  regarding  the 
expediency  of,  especially  the  primary,  exarticulation  of  the  hip." 

*  Arch.f.  Klin.  Chir.,  1874,  Bd.  xvi.  S.  309-316.    The  recoveries  seem  to  have  been 
twenty-five  out  of  eighty-eight  cases  so  treated, 
t  System  of  Surgery,  vol.  i.  p.  561. 


EXCISION    OF   THE    HIP.  861 

Operation.  —  Two  will  be  described  here :  A.  By  posterior 
incision  ;  T>.  By  anterior  incision. 

A.  Posterior  Incision  (Fig.  153). — The  chief  advantage  of  tins  is 
its  better  drainage,  a  point  which  outweighs,  in  my  opinion,  the 
smaller  interference  with  muscles  entailed  by  the  incision  in  front 
(p.  863). 

While  the  patient  is  being  brought  under  ether,  a  stirru))  is  applied 
if  weight-extension  is  to  be  made.*  The  child  being  rolled  over  on 
to  his  sound  side,  and  the  parts  thoroughly  cleansed,  the  surgeon 
stands  usually  outside  the  limb,  the  patient's  body  being  in  either 
case  placed  conveniently  at  the  edge  of  the  table,  one  assistant 
supporting  the  limb,  while  another  is  opposite  to  the  surgeon.  An 
incision,  about  3?  inches  long,t  is  now  made  over  the  middle^  of  the 
great  trochanter,  commencing  about  midway  between  the  top  of  this 
bone  and  the  anterior  superior  spine,  and  ending  over  the  shaft,  just 
below  the  trochanter.  The  incision  should  curve  slightly  forwards 
and  pass  down  to  bone  or  cartilage,  as  the  case  may  be,  at  once.  Any 
bleeding  vessels  being  secured,  the  exact  position  of  the  head  and  neck 
is  now^  made  out  by  an  aseptic  finger,  aided  by  an  assistant  rotating 
the  limb.  A  second  incision  opens  the  capsule  freely.  '\\'ith  a  peri- 
osteal elevator,  aided  by  a  knife,  the  muscles  attached  to  the  great 
trochanter  are  detached,  the  cartilage  in  young  subjects  peeling  off 
with  them  in  one  or  more  pieces.  The  finger  is  now  passed  round 
the  neck  of  the  femur,  and  the  soft  parts,  including  the  periosteum, 
detached  as  much  as  possible  on  the  inner  side.  The  finger  now 
feeling  that  the  upper  part  of  the  trochanter  and  the  neck  of  the  bone 
are  free,  and  protecting  the  soft  parts  on  the  inner  side,  the  bone  is 
sawn  through  just  below  the  top  of  the  trochanter  with  an  osteotomy, 
metacarpal,  or  keyhole  saw.§  This  division  should  be  thoroughly 
and  cleanly  effected  without  splintering.     If  it  be  preferred,  in  addi- 

*  There  is  no  occasion  to  apply  an  Esniarch's  bandage  above  tlie  wound  ;  and 
rendering  the  limb  evascidar,  save  by  elevati()n,  is  often  rendered  impossible  by  the 
presence  of  an  abscess  or  sinuses. 

f  This  is  usually  sufficient  in  a  child.  But  it  must  be  always  remembered  that  a 
small  wound,  by  giving  insufficient  room,  leads  to  bruising  and  difficulty. 

+  The  advantage  of  going  as  far  forward  as  this  is,  that  the  fle'^hy  and  vascular  parts 
of  the  muscles  attached  to  the  great  trochanter  are  better  avoided. 

§  The  section  of  the  bone  should  always  be  made  while  this  is  in  situ.  The  plan  of 
dislocating  the  head  by  adducting  the  limb,  and  tiien  sawing  it  off,  disturbs  the  parts 
more,  and  runs  the  risk  of  fracturing  the  wasted  femur  of  a  little  child,  an  accident 
which  I  have  seen  occur  in  the  hands  of  a  %'ery  careful  operator.  Mr.  Wright  {Inc. 
supra  cit.  p.  101)  states  that  he  had  one  case  among  his  earlier  operations,  and  that  he 
has  also  separated  the  lower  epiphysis  in  an  infant  while  manipulating  the  femur 
during  incision  of  the  joint.  He  points  out  another  objection — viz.,  the  ease  witli 
which  the  periosteiim  may  be  stripped  off  if  the  head  of  the  bone  is  thrust  out. 


S62 


OPERATIOXS    OS   THE    LOWER    EXTREMI  PY. 


tion  to  the  protection  of  the  finger  on  the  inner  side,  a  blunt  dissector 
may  he  passed  behind  the  bone  as  well,  but  this  is  not  essential : 
retraction  will  protect  the  lips  of  the  wound  from  the  saw.  With  the 
aid  of  the  finger  and  an  elevator,  or  with  a  lion-forceps,  the  head 
and  neck  of  the  bone  are  levered  out  of  the  acetabulum,  this  being 
often  attended  with  some  difficulty  unless  the  capsule  has  been  very 

Fig..  153, 


Excision  of  the  liip.    The  saw  is  applied  rather  lower  down  than  usual.    Above  the  great 
trochanter  the  neck  and  head  are  seen  indistiactly. 

freely  o])ened.  The  ligamentum  teres  is  probably  destroyed;  if  not, 
it  must  be  divided.  The  acetabulum  is  then  examined,  and,  if  merely 
roughened,  left  alone;  if  pitting  or  erosion  are  present,  gouging  must 
be  resorted  to.* 

Any  bleeding  points  are  now  looked  to,t  and  drainage  provided  to 
the  very  bottom  of  the  acetabulum.     No  sutures  should  be  inserted. 

Site  of  Section  of  the  Fcmvr. — Having  tried  both,  I  think  that  the 
section  through  the  great  trochanter  (i.e.,  just  below  its  upper  margin) 
is  preferable  to  one  above  it  (i.e.,  through  the  neck).  This"  has  the 
advantges  of  disturbing  and  damaging  the  attachments  of  muscles 
much  less,  and  thus  leads  to  more  rapid  healing  and  far  greater  mo- 
bility  of  the  limb.     These,  however,  are  outweighed  by  the  disad- 

*  Any  sequestra  present  must  be  removed.  If  the  acetabulum  is  perforated,  and 
pus  present  on  its  pelvic  aspect,  free  exit  must  be  provided  by  means  of  a  gouge  or 
small  trephine,  and  a  drainage-tube  passed  through. 

t  The  hseinorrhage  is  usually  very  slight  Firm  plugging  around  the  drainage-tube 
with  strips  of  sal  alenibroth  or  iodoform  ganze  will  arrest  troublesome  oozing,  and  is 
preferable  to  spending  time  in  trying  to  secure  vessels,  unless  these  spring  distinctly. 


EXCISION    OF   THE    HIP.  863 

vantage  which  leaving  such  a  large  piece  of  bone  as  the  trochanter 
entails — viz.,  that  after  healing,  this  process  gets  drawn  up  against 
the  scar  and  constantly  frets  it.*  It  is  also  said  to  check  the  escape 
of  discharges,  and  to  render  the  patient  liable  to  persistence  or  recur- 
rence of  the  disease.  I  am  doubtful  as  to  the  last  two,  but  the  first  is 
absolutely  certain. 

B.  Anterior  Incision. — Mr.  R.  W.  Parker  has  advocated  this 
method  from  its  interfering  less  with  the  muscles  and  the  blood- 
supply.  He  expresses  his  belief  (Clin.  Soc.  Trans.,  \o\.  xiii.  p.  108) 
"that  any  incision  which  opens  the  hip-joint  from  behind  is  a  little 
unsurgical  as  an  operation,  for  it  must  necessarily  cut  across  a  large 
mass  of  very  important  muscles ;  and,  furthermore,  it  must  interfere 
largely  with  the  vascular  anastomoses  about  the  trochanter  as  well  as 
the  joint.  Thus  the  three  glutfei,  the  pyriformis,  obturator  internus, 
quadratus  femoris,  and  possibly  some  fibres  of  the  adductor  magnus 
will  be  divided."! 

I  doubt  very  much  whether,  if  this  method  is  largely  tried,  the 
above  advantages  will  be  found  to  outweigh  the  serious  disadvantage 
of  inferior  drainage,  and  perhaps  that  of  a  good  deal  of  bruising  of 
the  soft  parts,  owing  to  the  greater  difficulty  in  turning  out  the  liend 
of  the  bone  in  this  position.  I  ought,  however,  with  regard  to  the 
latter  objection,  to  say  at  once  that  I  have  no  personal  experience  of 
this  method  :  having  used  in  my  eighteen  cases  the  posterior  in- 
cision, I  should  be  very  unwilling  to  give  up  what  I  think  most 
surgeons  will  consider  the  very  superior  drainage  which  this  gives. 
On  this  point  we  are  in  need  of  more  information.  Thus,  of  the  six 
cases  given  by  Mr.  Parker  in  his  paper,  one  only  was  successful,  and 
this  was  operated  on  by  the  usual  posterior  incision.  Of  the  two  in 
which  the  incision  in  front  is  stated  to  have  been  used,  the  cases  were 
progressing,  but  were  still  under  treatment.  Of  the  other  three,  in 
one  amputation,  and  not  excision,  was  performed ;  in  the  remaining 
two  excision  was  resorted  to,  but  the  kind  of  incision  is  not  stated. 
One  of  these  had  improved,  but  still  had  sinuses,  and  could  not  walk  ; 
the  other  had  not  improved. 

Mr.  Barker  has  recently  advocated  this  method,  regarding  it  "as 

*  About  ten  years  ago  I  made  use  of  tliis  nietliod  in  one  case,  sawing  the  bone 
tliiough  tlie  neck  and  leaving  tlie  trociianter  entire.  A  rapid  recovery  took  place, 
and  the  boy  quickly  recovered  power  over  the  limb.  He  has  long  been  able  to  run 
and  climb  like  other  lads,  and  the  movements  of  flexion,  extension,  abduction,  and 
adduction  are  extraordinarily  perfect.  He  has,  however,  been  under  my  care  on 
several  occasions  for  superficial  ulceration  of  the  scar,  which  is  fretted  by  the  very 
prominent  upper  margin  of  the  immediately  subjacent  trochanter. 

t  Mr.  Barker  (K.C.S.  Lect.,  infra  cit.)  claims  another  advantage  for  this  method — 
viz,  that  the  wound  being  in  front  enables  the  patient  to  be  placed  on  a  double 
Thomas's  splint  a  week  or  so  after  operation,  and  to  be  more  easily  moved. 


864  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

superior  in  every  way  to  the  older  method,  and  as  likely  to  become 
the  operation  par  excellence  in  all  early  cases  of  hip-joint  disease." 

Mr.  Barker,  in  his  recently  delivered  Himterian  Lectures,  gives  the 
following  most  interesting  information  on  the  above-alluded-to  matter 
of  drainage.  It  will  be  understood  that  his  remarks  refer  to  operation 
in  early  cases.  While  it  is  much  to  be  desired  that  we  should  have 
further  information  in  the  shape  of  carefully  reported  cases,  hospital 
surgeons  will  agree  that  if  Mr.  Barker  succeeds  in  proving  his  point, 
he  will  have  done  more  for  the  surgery  of  hip-joint  disease  than  almost 
any  other  surgeon.  I  have  quoted  the  passage,  owing  to  its  absorbing 
interest,  in  extenso.  "  Except  for  the  drain-openings,  such  wounds 
heal,  in  my  experience,  as  a  rule,  by  first  intention.  The  fluid,  more- 
over, after  the  first  day  or  so,  which  comes  from  the  drain-tube,  is 
little  more  than  thick,  odorless  serum.  It  exudes  in  very  small 
quantity,  and  ought  never  to  become  truly  purulent.  This  is  the 
reason  why  the  opening,  although  anterior,  is  perfectly  adequate  for 
the  drainage  of  the  cavity  left  by  the  operation.  I  have  often  been 
asked,  '  Do  you  find  this  anterior  incision  gives  sufficient  drainage 
for  discharges?'  My  answer  always  is,  '  Certainly,  for  there  are  no 
discharges  worth  mentioning  after  the  first  oozing  of  blood  and  serum 
immediately  following  operation.'  Those  who  ask  this  question  have, 
doubtless,  in  their  eye,  the  older  experiences  of  excision  of  the  hip, 
when  the  operation  was  usually  undertaken  in  an  advanced  stage  of 
the  disease,  when  suppuration  had  already  set  in  freely,  with  rami- 
fying sinuses.  I  am  not  alluding  to  such  cases,  believing,  as  I  do, 
that  experience  shows,  and  es[iecially  Mr.  Marsh's  figures  alluded  to 
already,  that,  beyond  aseptic  drainage,  they  are  best  left  to  Nature, 
and  are  unsuitable  for  excision.  But  in  relatively  early  cases  treated 
carefully,  as  just  described,  we  have  lisiially,  and  ought  always  to  have, 
healing  without  any  suppuration  at  all,  properly  so  called.  I  could 
produce  a  series  of  cases,  illustrating  this  fact,  from  my  own  practice 
and  from  that  of  my  colleague,  Mr.  Bilton  Pollard,  who  operates  on 
exactly  the  same  lines  at  the  Children's  Hospital,  and  I  believe  other 
surgeons  have  found  the  same  thing.  It  must  not  be  forgotten  that 
when  an  excision  is  performed  early,  and  all  tuberculized  tissue  is 
removed,  a  clean-walled  cavity  is  left,  most  of  which  is  quite  capable 
of  healing  by  first  intention,  when  its  different  surfaces  are  brought 
into  contact  by  firm  pressure.  And  in  these  cases,  the  head  of  the 
bone  being  removed,  and  the  acetabulum  quite  clean,  the  cut  surface 
of  the  neck  of  the  femur  can  be  brought  close  up  to  the  latter,  so  that, 
although  there  is  potentially  a  large  space  in  the  field  of  operation, 
there  ought  to  be  actually  little  or  no  cavity  left,  if  pressure  have  been 
properly  applied  from  the  first.  There  is  no  need,  then,  in  such 
cases,  after  the  first  day  or  two,  for  extensive  drainage  if  the  wound 


EXCISION    OF   THE    HIP.  865 

be  kept  aseptic.  If  it  is  not  so,  of  course  the  case  is  totally  different, 
and  drainage  is  absolutely  necessary.  For  my  own  part,  I  intend  to 
try  whether  some  of  these  early  excisions  cannot  be  left  to  heal  abso- 
lutel}^  by  first  intention,  without  any  drainage  at  all,  just  as  in  many 
cases  tubes  can  be  dispensed  with  altogether  in  analogous  cases  of 
operation  on  the  knee." 

As  I  have  said  before,  this  question  can  alone  be  settled  after  a 
large  number  of  cases  have  been  published.  Surgeons  will,  iio  doubt, 
follow  Mr.  Barker,  and  test  this  method  widely.  Most  will,  I  think, 
begin  by  draining  the  deepest  cavity  of  the  wound  by  a  tube  brought 
out  by  counter-puncture  on  the  outer  aspect  of  the  thigh,  in  the  event 
of  their  cases  not  running,  so  smooth  a  course  as  Mr.  Barker's.  Two 
expressions  in  the  above  most  interesting  remarks  require  attention — 
first,  where  Mr.  Barker  says,  "  when  an  excision  is  performed  early 
and  all  tuberculized  tissue  is  removed  ;  "  the  second,  "  in  these  cases, 
the  head  of  the  bone  being  removed,  and  the  acetabulum  quite  clean." 
I  fear  these  most  desirable  conditions  will  be  found  most  difficult  to 
secure  absolutely,  even  if  early  excision  is  resorted  to,  but  I  would 
not  in  this  put  a  mere  opinion  before  Mr.  Barker's  experience.  We 
must  wait  for  that  light  which  carefully  reported  cases  alone  give. 

Operation. — The  patient  being  on  his  back,  with  the  limb  ex- 
tended, and  the  parts  duly  cleansed,  the  surgeon  standing,  in  the 
case  of  either  limb,  on  the  right  side,  makes  an  incision  3  to  4  inches 
long,  starting  immediately  below  the  anterior  superior  spine  down- 
wards, and  slightly  inwards,  between  the  tensor  vaginae  and  glutei 
externally  and  the  sartorius  internally.  The  upper  part  of  this 
incision  should  pass  down  to  the  capsule  at  once,  the  lower  third 
should  divide  skin  only.  A  second  incision  in  the  upper  part  of  the 
first  should  certainly  open  the  capsule.  An  aseptic  finger  now  ex- 
amines the  condition  of  the  joint.  The  wound  being  opened  by 
retractors,  a  narrow-bladed  saw  is  introduced  in  the  upper  part,  and 
the  neck  of  the  bone  is  divided  from  above  downwards,  in  situ,  and 
•with  as  little  damage  to  the  soft  parts  as  possible.  The  head  of  the 
femur  is  now  extracted  and  the  acetabulum  treated  bj'  the  means 
given  at  p.  862.  The  remaining  steps  should  be  carried  out  after  Mr. 
Barker's  directions.*  "Every  trace  of  diseased  synovial  tissue  dis- 
coverable is  now  removed  with  scissors,  knife,  and  sharp  spoon, 
special  care  being  also  taken  to  clear  out  any  caseating  abscesses 
communicating  with  the  joint.  All  this  should  be  done  with  as  little 
violence  to  the  tissues  around  as  possible,  so  that  none  of  the  tuber- 
cular debris  shall  be  forced  into  its  fresh-cut  surfaces.  When  every 
portion  of  the   diseased   tissue  has  been   thoroughly  removed,  the 

*  R.C.S.  Lect.,  Brit.  Med.  Journ.,  p.  1326. 
55 


866  OPERATIONS   ON   THE    LOWER    EXTREMITY. 

cavity  is  freely  flushed  with  some  germicide  solution  until  all  loose 
particles  have  been  waslied  away.  It  is  then  sponged  dry  from  the 
bottom,  and  is  immediately  dusted  with  iodoform,  Avhich  may  be 
carried  further  into  the  ramifications  of  the  cavity  on  the  end  of  the 
finger.  It  is  well,  I  think,  after  this,  again  to  introduce  a  small 
sponge  for  the  purpose,  not  only  of  drying  the  part,  but  also  for 
wiping  away  any  excess  of  iodoform  which  may  be  about.  This 
sponge  should  be  left  in  until  the  sutures  which  close  the  wound  are 
in  position  and  are  ready  to  be  tied.  It  is  then  removed  and  the 
threads  are  knotted,  a  medium-sized  drainage-tube  being  carried 
down  as  far  as  the  acetabulum." 
Usual  Causes  of  Failure  after  Excision  of  the  Hip. 

1.  Persistent  pelvic  disease. 

2.  Chronic  osteo-myelitis  of  sawn  end  of  femur. 

3.  Suppuration  and  hectic. 

4.  Lardaceous  disease. 

5.  Tubercular  conditions  elsewhere.     General   outbreak  of  tuber- 
culosis. 

6.  Disease  of  the  opposite  femur. 


CHAPTER  II. 

OPERATIONS  ON  THE  THIGH. 

LIGATURE  OF  THE  COMMON  FEMORAL —LIGATURE 
OF  THE  SUPERFICIAL  FEMORAL  IN  SCARPA'S  TRI- 
ANGLE.-LIGATURE  OF  THE  SUPERFICIAL  FEMO- 
RAL IN  HUNTER'S  CANAL.— PUNCTURED  AND  STAB 
WOUND  IN  MID-THIGH. -AMPUTATION  THROUGH 
THE  THIGH. -AMPUTATION  IMMEDIATELY  ABOVE 
THE  KNEE  -  JOINT.  -  REMOVAL  OF  EXOSTOSIS 
FROM  NEAR  THE  ADDUCTOR  TUBERCLE.  -  UN- 
UNITED FRACTURE  OF  THE  FEMUR. 

LIGATURE  OF  THE  COMMON  FEMORAL. 

Though  this  operation  is  not  regarded  with  much  favor,  especially 
for  aneurism,  it  will  be  described  here,  as  the  question  of  tying  it  arises 
from  time  to  time,  and  as  it  should  always  be  performed  for  the  sake 
of  practice,  on  the  dead  body. 

Indications. 

1.  Wounds. — These  are  rare  here  compared  with  those  affecting  the 
vessels  lower  down.     The  wound  must  always  be  explored  and  the 


LIGATURE   OF   THE   COMMON    FEMORAL,  867 

bleeding-point  sought,  for  two  reasons — (a)  Ligature  of  the  external 
iliac  will  usually  fail  to  arrest  bleeding  from  the  common  femoral. 
(6)  The  source  of  the  bleeding  may  easily  be  mistaken  here ;  thus,  Mr. 
Liston,*  in  a  case  of  pistol-shot  wound  of  the  groin,  tied  the  external 
iliac  for  what  was  })roved,  post  mortem,  to  have  been  a  wound  of  "  one 
of  the  superficial  branches  of  the  common  femoral,  about  j  inch  below 
Poupart's  ligament." 

After  ligature  for  gun-shot  injuries,  whether  for  direct,  or  for  con- 
secutive bleeding  unattended  by  primary  injury  to  the  vessel,  the 
mortality  in  the  American  warf  seems  to  have  been  high — over  70  per 
cent. 

The  very  important  subject  of  ligature  of  the  femoral  artery  or  vein, 
or  both,  in  cases  of  wounds,  will  be  referred  to  here,  though  briefly. 
Such  cases  will  arise  most  frequently  in  removal  of  growths — e.g.,  epi- 
theliomata,  lymphomata,  sarcomata,  less  often  in  cases  of  stabs. 
Much  interesting  information  on  these  subjects  will  be  found  in  papers 
by  M.  Kirmisson;};  and  Dr.  L.  Pilcher.§ 

2.  Removal  of  Growths  from  Scarpa's  Triangle  and  Injur}'  to  Fem- 
oral Vessels.  M.  Kirmisson  has  lately  drawn  attention  to  the  following 
points :  In  the  course  of  the  deeper  dissection  the  pidsation  of  the 
femoral  artery  should  be  frequently  felt  for  with  the  finger.  As  this 
vessel  may  have  been  displaced  it  is  not  enough  to  trust  to  anatomical 
knowledge  alone.  After  separating  the  structures  on  either  side  of  the 
tumor,  this  should  be  left  adherent  where  in  connection  with  the 
sheath,  and  especial  care  devoted  to  this  spot.  Where  the  adhesions 
are  very  firm,  and  where  a  large  tumor  surrounds  the  sheath,  it  is 
useful  to  divide  the  tumor  and  to  remove  large  parts  of  it,  only  pre- 
serving that  part  in  intimate  connection  with  the  vessels,  this  being 
finally  separated  most  carefully.  In  the  case  of  growths  in  intimate 
connection  with  the  sheath  the  vein  is  particularly  in  danger,  because 
(a)  the  vein-walls  are  much  more  quickly  invaded  than  the  arterial, 
and  {b)  the  vein  is  in  closer  connection  with  the  glands.  Two  con- 
ditions are  likely  to  be  met  with  b}' the  surgeon:  1.  Denudation  of 
the  vessels.  Here  the  adhesions  are  sufficiently  loose  to  be  separated, 
and  the  sheath  is  either  left  intact  or  opened.     Every  effort  must  be 

*  Med.-Chir.  Trans.,  vol.  xxix.  p.  107.  Tlie  flow  of  blood  here  is  said  to  have  been 
"  most  impetuous  and  profuse."  In  Mr.  Liston's  words:  "The  division  of  even  a  small 
branch  close  to  the  principal  vessel,  it  is  well  known,  pours  out  blood  furiously,  as 
much  so,  in  fact,  as  if  an  opening  in  the  coats  of  the  artery  itself  were,  so  to  say, 
punched  out,  corresponding  in  size  to  the  area  of  the  branch." 

f  Otis,  Medical  and  Surgiad  History  of  the  War  of  the  Rebellion,  |)art  iii.  pp.  I'',  43,  49. 

X  Rev.  de  Chir.,  May  10,  18<S6.  I  am  indebted  for  my  knowledge  of  this  paper  to  an 
abstract  by  Mr.  T.  Jones,  of  Manchester  (Med.  Chron.,  September,  188(3,  p.  514). 

§   Annals  of  Surgery,  February,  188H. 


868  OPERATIONS   ON    THE   LOWER    EXTREMITY. 

taken  to  keep  the  wound  here  aseptic.  2.  Resection  and  ligature  of 
one  or  other  of  the  femoral  vessels.  If  the  vein  alone  has  been  injured 
in  an  operation  or  by  a  stab  it  should  be  secured,  if  possible  by  a  later- 
ally applied  ligature,  or  by  the  application  of  Spencer  Wells's  forceps 
left  in  situ  for  two  or  three  days.*  These  being  impo'ssible,  or  failing, 
the  femoral  vein  must  be  ligatured.  Dr.  Pilcher,  quoting  from  a  paper 
of  Braun's,t  shows  that  of  eighteen  cases  in  Avhich  ligature  of  the 
femoral  vein  alone  was  practiced  at  the  level  of  Poupart's  ligament, 
thirteen  occurred  as  the  result  of  wounds  inflicted  during  the  removal 
of  tumors.  In  none  of  these  tvimor-extirpation  cases  did  gangrene 
ensue. I 

The  question  has  been  raised  lately  whether,  when  ligature  of  the 
common  femoral  vein  has  been  found  needful,  tlie  common  femoral 
artery  should  not  be  tied  also,  in  order  to  diminish  the  risk  of  gan- 
grene. Dr.  Pilcher,  while  quoting  the  cases  of  Roux,  Linhart,  and 
Langenbeck,  in  which  this  step  was  successful,  shows  that  the  practice 
of  ligature  of  the  common  femoral  artery  as  a  prophylactic  step  after 
wound  of  the  common  femoral  vein  high  up,  Avhether  in  the  removal 
of  tumor  or  in  injuries,  e.g.,  stabs,  is  to  be  discouraged. § 

Dr.  Pilcher  suggests  (loc.  supra  ciL,  p.  119)  that  where  the  femoral 
vein  has  been  suddenly  and  completely  occluded  high  up  it  will  be 
wiser  to  tie  not  the  common  but  the  superficial  femoral  artery,  as 
likely  to  materially  diminish  the  current  to  the  limb,  while  the 
amount  provided  will  be  quite  sufficient  for  its  nutrition. 

In  cases  where  both  vein  and  artery  are  wounded  these  must  be 
secured  m  situ.  The  risk  pf  gangrene  is  now  enormously  increased, 
though  the  risk  will  vary  somewhat  accordingly  as  the  simultaneous 
ligature  is  made  above  or  below  the  deep  femoral. 

A  few  other  points  bearing  upon  the  removal  of  tumors  here  may 
be  alluded  to.     The  internal  saphena  vein  should  be  carefully  pre- 

*  A  case  in  which  I  thus  treated  a  wound  of  the  internal  jugular  has  been  recorded 
at  p.  410.  Piiclier  mentions  a  case  of  Kuester's,  in  whicli  a  wound  in  the  vein  was 
secured  with  hsemoslatic  forceps;  the  removal  of  these  after  only  twenty-fours  hours 
was  followed  by  renewed  bleeding,  ligature  of  the  femoral  artery,  and  fatal  gangrene. 

t  Arch.f.  Klin.  Chir.,  Bd.  xxviii.  Heft  3,  S.  610. 

J  Dr>  Pilcher  points  out  that  this  is  due  to  tlie  gradual  enlargement  of  the  collateral 
venous  ciifculation  which  takes  place  during  the  growth  of  the  tumor.  This  constitutes 
a  most  important  diflerence  between  woinids  ot  the  vein  during  operation  and  by  a 
stab.  Thus,  in  five  cases  in  which  as  tlie  result  of  acute  injuries  the  femoral  vein  was 
tied  high  up,,  recovery  without  disturbance  took  place  in  only  one.  In  two,  deatli  took 
place  from  septicaemia  and  py?emia;  in  tiie  remaining  two,  gangrene  rapidly  super- 
vened. 

I  In  support  of  this,  Dr.  Pilcher  writes :  "To  diminish,  to  an  extreme  degree,  the 
arterial  supply  to  a  part  whose  nutrition  is  already  seriously  compromised  by  general 
venous  stasis,  would  certainly  tend  to  precipitate  and  aggravate  the  threatened  necrosis." 


IJGATURE   OF   THE    COMMON    FEMORAL.  869 

served  intact,  and  where  it  is  realh^  needful  to  divide  it,  this  should  be 
done  as  far  from  the  main  femoral  trunk  as  possible,  otherwise  most 
troublesome  cedema  may  subsequently^  develop.* 

In  operating  close  to  Poupart's  ligament,  and  especially  on  the  inner 
side,  the  presence  of  the  peritoneum, f  and  the  possible  existence  of  a 
femoral  hernia  must  be  remembered. 

3.  Aneurism. — There  has  been  much  difference  of  opinion  as  to 
whether  it  is  wiser,  when  dealing  with  an  aneurism  on  the  supeiiicial 
femoral  high  up,  to  tie  the  common  femoral  or  the  external  iliac. 
English  surgeons  have  rejected  ligature  of  the  common  femoral  for 
these  reasons:  (1)  The  risk  of  gangrene  a?  the  ligature  is  placed 
above  both  the  great  nutrient  arteries  of  the  limb.  (2)  The  probability 
of  firm  clotting  taking  place  after  the  ligature  is  rendered  doubtful, 
owing  to  the  number  of  small  vessels  given  off"  here — viz.,  the  super- 
ficial epigastric,  and  circumflex  iliac,  the  superior  and  inferior  ex- 
ternal pudic,  and  very  commonly  one  of  the  circumflex  arteries,  and 
also  by  the  proximity  of  the  profunda.  (3)  The  uncertainty  of  the 
origin  of  the  profunda,  and  thus  of  the  length  of  the  common  femoral. 
(4)  I  would  add  to  the  above  that  ligature  of  the  common  femoral  for 
aneurism  approximates  the  treatment  to  that  of  Anel  rather  than  to 
that  of  Hunter.  Erichsen|  goes  so  far  as  to  say,  "  It  may  be  laid 
down  as  a  rule  in  surgery,  that  in  all  those  cases  of  aneurism  which 
are  situated  above  the  middle  of  the  thigh,  in  which  compression  has 
failed  and  sufficient  space  does  not  intervene  between  the  origin  of 
the  deep  femoral  and  the  upper  part  of  the  sac  for  the  application 
of  a  ligature  to  the  superficial  femoral,  the  external  iliac  should  be 
tied." 

Mr.  Holmes, §  while  adducing  facts  to  show  that  the  operation  on 
the  common  femoral  is  not  in  itself  by  any  means  so  fatal  as  has  been 
represented,  and  that  no  just  cause  whatever  has  been  shown  for 
banishing  it  from  surgical  practice,  allows  that  he  should  be  in  favor 
of  ligature  of  the  external  iliac  for  femoral  aneurism  high  up,  under 
ordinary  circumstances,  and  reserve  that  on  the  common  femoral  for 
cases  where  the  bell}^  is  extremely  fat. 

The  opposite  opinion  has  been  held  by  some  of  the  Irish  surgeons 
— viz.,  the  two  Porters,  Mr.  Smyly,  Mr.  Butcher,  and  Dr.  Macnamara, 


*  Dr.  Pilcher  {Inc.  mipra  ell.,  p.  114)  mentions  a  case  where,  after  ligature  of  tlie 
saphena  vein  close  to  the  coninion  femoral,  the  tendency  to  (B.iema  was  so  great  that 
the  patient,  nnfitted  for  work,  begged  for  removal  of  the  limb. 

t  M.  Kermisson  mentions  a  case  in  which  the  peritoneum  was  wounded  and 
siitwred,  the  patient  recovering. 

X  Surgery,  vol.  ii.  p.  244. 

g  Hunt.  Lect.,  Lancet,  1874,  vol,  ii.  p.  300. 


870  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

The  last-mentioned  surgeon  has  published*  eight  cases,  of  which  six 
were  successful,  two  dying  of  haemorrhage. 

It  is  probable,  however,  that,  for  the  reasons  given  above,  ligature 
of  the  external  iliac  will  be  preferred,  especially  as  nowadays  anti- 
septic precaution  and  improved  ligatures  will  have  rendered  this 
operation  increasingly  safe. 

4.  Ulceration  of  the  Artery  by  Growth. — From  the  frequency  of 
growths  here  this  indication  will  occasionally  arise.  I  have  met  with 
one  case.  A  man  was  admitted  under  my  care  who  had  been  operated 
on  elsewhere  for  the  removal  of  sarcomatous  glands  in  the  groin. 
The  application  of  zinc  chloride  paste  had  led  to  detachment  of 
sloughs  and  exposure  of  the  common  femoral,  which  gave  way,  lead- 
ing to  profuse  haemorrhage.  I  tied  the  common  femoral  immediately 
above  the  bleeding-point;  this  was  sloAvly  followed  by  typical  dry 
gangrene,  necessitating  amputation  throvigh  the  lower  third  of  the 
thigh. 

5.  As  a  Preparatory  Step  to  Amputation  at  the  Hip-joint. — The 
need  of  this  has  been  largely  done  away  with  by  the  Furneaux  Jor- 
dan method.  Where  this  is  not  available,  one  of  the  other  means 
given  at  p.  845  will,  I  think,  be  found  preferable. 

Line  and  Guide. — From  a  point  midway  between  the  anterior  su- 
perior spine  of  the  ilium  and  symphysis  pubis  to  the  adductor  tuber- 
cle, or  the  inner  margin  of  the  internal  condyle. 

Another  line  is  sometimes  taken  from  the  centre  of  Poupart's  liga- 
ment (or  a  point  midway  between  the  two  spines)  to  the  inner  margin 
of  the  patella  or  the  front  of  the  internal  condyle,  but  that  above  given 
is  the  more  correct. 

Relations  :  In  Front. 

Skin  ;  faseiie ;  lymphatic  glands. 
Sheath. 
Outside.  Inside. 

Anterior  crural.  Septum  of  sheath. 

Common  femoral.  Femoral  vein. 

Behind. 

Sheath. 
Psoas. 

It  is  important  to  note  that  the  common  femoral  is  usually  only  li 
inch  long,  and  that  from  it  come  off  not  only  the  superficial  epigastric, 

*  Brit.  Med.  Journ.,  October  5,  1867.  Mr.  G.  H.  Porter  (Dub.  Joum.  Med.  Sci.,  vol. 
XXX.  N.S.  1860,  p.  302)  reports  three  cases,  and  alludes  to  two  under  his  fatlier's  caie. 
All  were  successhil,  though  s<econdary  hseiuorrhage  occurred  in  two. 


LIGATURE   OP    FEMORAL    IN   SCARPa's    TRIANGLE.  871 

circumflex  iliac,  and  superior  and  inferior  external  pudic,  but  occa- 
sionally one  of  the  circumflex  arteries  as  well. 

Collateral  Circulation. 

Above.  Below. 

Glutaeal  and  sciatic,  with         Superior  perforating  and  cir- 

cumflex arteries. 

Superficial  circumflex  iliac,  with  Ascending  branch  of  exter- 
nal circumflex. 

Obutrator,  with         Internal  circumflex. 

Comes  nervi  ischiadici,  with         Perforating  of  profunda  and 

articular  of  popliteal. 

Operation. — The  groin  being  shaved  and  cleansed,  the  hip  and 
knee  semiflexed,  and  the  limb  adducted  and  rotated  somewhat 
outwards,  an  incision  about  2*  inches  long  is  made  in  the  line  of  the 
art^r}^  commencing  just  above  Poupart's  ligament.  The  skin  and 
superficial  fascia  being  divided,  and  any  overlying  glands  displaced 
or  removed,  any  veins  which  may  be  met  with  descending  to  join  the 
internal  saphena  are  either  drawn  aside  or  tied  between  double  liga- 
tures of  chromic  gut.  The  fascia  lata  being  opened  just  below  Pou- 
part's ligament,  the  artery  or  its  pulsation  is  felt  for,  the  vessel  exposed 
here,  and  the  needle  passed  from  within  outwards,  care  being  taken 
to  avoid  the  crural  branch  of  the  genito-crural,  which  lies  superficial 
to  the  artery.  The  neighborhood  of  any  branch  is,  if  possible, 
avoided.  A  horse-hair  drain  is  then  inserted,  and  the  wound  care- 
fully closed. 

By  another  method  the  artery  is  found  by  an  incision  parallel  with 
the  centre  of  Poupart's  ligament  and  about  i  inch  below  it.  This  is 
recommended  by  Mr.  Porter  and  Dr.  Macnamara  (loc.  supra  cit.).  Of 
the  two,  the  first  in  the  line  of  the  vessel  is  to  be  preferred. 

LIGATURE  OF  THE  SUPERFICIAL  FEMORAL  IN 
SCARPA'S  TRIANGLE  (Fig.  154). 

Indications. 

1.  Certain  Cases  of  Aneurism  of  the  Popliteal  Artery  or  the  Femo- 
ral low  down. — Thus  the  ligature  will  probably  be  indicated — (a) 
where  a  popliteal  aneurism  is  rapidly  growing,  especially  when  (b)  it 
is  on  the  anterior  aspect  of  the  artery  instead  of  behind  or  atone  side 
of  it,  as  in  the  former  case  the  knee-joint  may  become  involved  after 
very  obscure  symptoms ;  (c)  when  the  aneurism  is  fusiform  rather 
than  saccular ;  (d)  when  it  has  very  thin  walls  ;  (e)  when  it  threatens 
to  burst,  or  when  this  has  already  happened,  unless  other  symptoms 
— e.g.,  gangrene — call  for  amputation  ;  (/)  if  visceral  disease — cardiac, 


872  OPERATIONS    OX    THE    LOWER    EXTREMITY. 

renal,  hepatic — or  an  atheromatous  condition  of  the  vessels  is  present, 
the  surgeon  must  weigh  carefully  the  question  of  operative  interfer- 
ence ;  I  should  prefer  in  most  cases  a  trial  of  the  ligature  as  likely, 
with  the  aid  of  antiseptic  precautions,  a  modern  ligature  and  primary 
union,  to  entail  less  taxing  of  the  patient's  powers :  (g)  where  a  trial 
01  pressure  has  failed,  or  is  certain  to  fail  from  the  irritability  of  the 
patient. 

2.  Wounds. — Nothing  need  be  added  here  to  what  has  been  said  on 
the  subject  at  pp.  875,  876. 

3.  For  Hemorrhage  low  down — e.g.,ixher  am])utation  in  the  middle 
of  the  thigh,  when  other  means  fail  and  the  wound  is  nearly  united 
(p.  876).  Two  other  instances  are  given  by  Mr.  Bryant  *  One  was 
"  a  case  of  Mr.  Bransby  Cooper's,  in  which  a  compound  fracture  of 
the  leg  was  complicated  with  a  laceration  of  the  femoral  artery.  The 
artery  was  secured  at  the  seat  of  injur3^  and  repair  went  on  well  in 
all  respects.  Mr.  Bransby  Cooper  has  also  recorded  in  his  Surgical 
Essays  a  case  of  fracture  of  the  femur  in  which  the  femoral  artery 
was  ligatured  for  a  ruptured  popliteal  artery,  and  in  which  recovery 
took  place  in  six  weeks."  Each  of  such  cases  must  be  considered  on 
its  own  merits,  but  the  aboveshows  what  ligature  of  the  femoral  artery 
will  do  in  appropriate  cases. 

4.  For  Elephantiasis. — Cases  in  which  the  superficial  femoral  has 
been  tied  will  be  found  in  the  Lancet  for  1879,  vol.  i.  p.  44  ;  and  Bank- 
ing's Abstract  for  1860,  vol.  ii.  p.  193.  The  subject  of  ligature  of  the 
main  artery  of  a  limb  for  this  affection  has  been  considered  at  p.  531. 

5.  Acute  Inflammation  of  the  Knee-joint. — Mr.  Maunder  brought  a 
case  before  the  Clinical  Society  (Trans.,  vol.  ii.  p.  37),  in  which,  at  his 
suggestion,  Mr.  Little  had  tied  the  femoral  artery  for  acute  inflamma- 
tion of  the  knee-joint,  ten  days  after  a  lacerated  wound.  The  pain 
and  other  acute  symptoms  were  at  once  relieved,  and  the  patient 
made  a  good  recovery.  The  antiseptic  treatment  of  wounds  of  joints 
aided  by  free  incisions  will,  nowadays,  do  away  with  the  need  of  the 
above  treatment. 

Line. — That  above  given,  p.  870. 

Guide. — The  above  line  and  the  inner  border  of  the  sartorius  at 
the  apex  of  the  triangle. 


Relations  : 


In  Front. 
Skin  ;  superficial  fascia ;  glands  ;  crural 
branch  of  genito  crural  nerve;  middle 
cutaneous  and  branch  of  internal  cu- 
taneous ;  fascia  lata ;  sartorius. 


*  Surgery,  vol.  ii.  p.  417. 


LIGATURE    OF    FEMORAL    IN    SCARPA  S   TRIANGLE. 


873 


Outside. 
Femoral  vein  (below).  Ante- 
rior crural  nerve,  and  some 
of  its  branches — viz.,  nerve 
to  vastus  internus,  and  long 
saphenous  nerve. 

Behind. 

Psoas ;  pectineus ;  adductor  longus  ;  femoral 
vein  (below) ;  profunda  vein ;  nerves  to 
pectineus. 


Inside. 

Femoral  vein  (above). 


Collateral  Circulation. 

Above. 
Perforating  of  profunda, 


External     circumflex    of 

profunda, 
Comes  nervi  ischiadici, 


with 


with 
with 


Below. 
Lower  muscular  of  femoral, 
articular  of  popliteal,  and 
anterior  tibial  recurrent. 

Ditto  ditto. 

Perforating    of      profunda, 
and  articular  of  popliteal. 


Operation  (Fig.  154). — The  parts  being  shaved  and  cleansed,  the 
knee  and  hip  slightly  flexed,  the  thigh  abducted  and  somewhat 
everted,  and  the  leg  resting  on  a  pillow,  the  surgeon,  seated  or  stand- 
ing to  the  right  of  the  affected  limb,  makes  an  incision  3  inches  long 
in  the  line  of  the  artery  (p.  870).  This  should  begin  about  2?  inches 
below  Poupart's  ligament,  and  run  down  to,  and  somewhat  below, 
the  apex  of  Scarpa's  triangle,  which  lies  usually  4  to  5  inches  below 
Poupart's  ligament.  The  skin  and  superficial  fascia  being  divided, 
any  small  vessels  are  secured,  and  branches  of  the  saphena  vein 
drawn  aside  with  a  strabismus  hook  or  secured  with  double  chromic- 
gut  ligatures.  The  deep  fascia  is  now  slit  up  for  the  whole  length  of 
the  wound,  and  the  inner  margin  of  the  sartorius,  which  crosses  the 
lower  part  of  the  incision,  identified.  This  is  then  turned  outwards, 
and  so  held  with  a  blunt  hook  or  retractor,  while  the  artery  or  its 
pulsation  is  felt  for.  The  wound  being  now  well  opened  out  with  re- 
tractors and  carefully  wijDcd  out,  the  sheath  is  opened  to  the  outside, 
care  being  taken  to  avoid  the  nerves  in  contact  with  it — viz.,  the  long 
saphenous,  or  the  nerve  to  the  vastus  internus.  The  artery  being 
cleaned,  thoroughly  but  most  carefully,  on  either  side  and  behind, 
the  needle  is  passed  from  within  outwards,  being  kept  very  close  to 
the  vessel  so  as  to  avoid  the  vein  which  lies  behind  and  internally.* 

*  The  vein  is  so  frequently  damaged  here,  especially  on  the  dead  subject,  that  a  few 
precautions  may  be  given  as  to  the  best  way  of  avoiding  it.  First,  the  sheath  must 
be  identitied  exactly,  and  sufficiently  opened  at  its  outer  part.     It  will  be  found  of 


874 


OPERATIONS    OX   THE    LOWER    EXTREMITY. 


The  artery  being  tied,  the  lig<ature  is  cut  short,  drainage  provided  by- 
horsehair  or  a  small  tube,  according  to  the  amount  of  disturbance  of 


Fig.  154. 


Fig.  155. 


Ligature  of  the  superficial  femoral  at  the 
apex  of  Scarpa's  triangle,  and  in  Hunter's 
canal.  Above,  the  sartorius  (the  only  struc- 
ture which  happened  to  be  met  with)  is  drawn 
outwards.  Below,  it  is  drawn  inwards.  The 
long  saphenous  nerve  lies  on  the  outer  side  of 
the  artery,  here. 


Incised  wound  of  the  thigh  explored  and 
found  to  involve  the  femoral  artery.  An  Es- 
march's  bandage  should  have  been  shown  in 
situ  above. 


much  help  in  cleaning  the  vessel  if  one  edge  of  the  cut  sheath  is  held  by  an  assistant, 
while  the  snrgeon  has  hold  of  the  other ;  the  opening  in  the  sheath  is  thus  made  sure 
of  and  retained.  There  mnst  be  no  needless  disturbance,  or  lifting  np  of  the  vessel 
upon  the  needle,  which,  with  the  director,  must  be  used  with  the  utmost  carefulness. 
As  soon  as  the  eye  (and  this  sljould  be  at  the  very  end  of  the  needle)  is  seen  to  have 
passed  round  the  vessel,  the  ligature  should  be  at  once  seized  and  the  needle  with- 
drawn. 


LIGATURE   OF    FEMORAL    IN    HUNTEr's    CANAL.  875 

the  parts,  etc.,  and  the  wound  closed.     The  precautions  given  at  p. 
535  for  the  prevention  of  gangrene  must  be  taken. 
Diflaculties  and  Mistakes. 

1.  Wounding  the  Saphena  Vein. — This  may  occur  if  the  incision 
is  made  too  internal.  It  is  always  to  be  avoided  if  possible,  owing 
to  the  troublesome  oedema  which  may  follow. 

2.  A  very  broad  Sartorius. 

3.  Injury  to  the  Femoral  Vein.— This  may  easily  take  place  if  force 
is  used  in  pushing  the  needle  round  an  imperfectly  cleaned  artery,  or 
if  the  needle  is  not  kept  close  to  the  vessel.  If  the  accident  occur, 
the  surgeon  must  not  persist  in  his  attempt  to  tie  the  artery  at  this 
spot,  a  course  which  will  only  end  in  his  inflicting  more  injury  on 
the  vein,  but,  finger-pressure  being  made  in  the  lower  angle  of  the 
wound,  the  artery  is  tied  either  above  or  below  the  spot  where  the 
vein  has  been  injured.  As  soon  as  the  artery  is  secured,  no  further 
hsemorrhage  will  take  place,  but  pressure  may  be  kept  up  by  means 
of  a  carbolized  sponge  over  the  wound  for  a  da}^  or  two.*  The  patient 
will  do  well  to  wear  a  Martin's  bandage  or  an  elastic  stocking  for 
some  time  after  getting  up. 

4.  Including  one  of  the  nerves. 

5.  A  matted  condition  of  the  parts  due  to  a  previous  trial  of  com- 
pression. 

Abnormalities  of  the  Femoral  Artery. 

1.  A  double  superficial  femoral,  the  two  trunks  uniting  below  to 
form  the  popliteal.  More  than  one  case  of  this  kind  is  recorded. 
The  persistence  of  pulsation  in  the  aneurism  after  the  first  ligature 
would  lead  to  a  suspicion  of  this  condition. 

2.  The  vessel  may  run  down  at  the  back  of  the  limb. 

LIGATURE  OF  FEMORAL  ARTERY  IN  HUNTER'S 
CANAL  (Fig.  154).  — TREATMENT  OF  STAB  IN  MID- 
THIGH  (Fig.  155). 

Indications  for  Ligature  of  the  Femoral  Artery  in  Hunter's 
Canal. 

1.  Wounds. — These  may  be,  (a)  incised;  (6)  punctured. 

(o)  Here,  if  immediate  death  from  haemorrhage  has  been  arrested, 
the  wounded  vessel  must  be  secured.  The  artery  above  being  com- 
pressed by  an  Esmarch's  bandage  or  the  hands  of  an  assistant,  the 
wound  is  enlarged,  clots  sponged  away,  and  the  artery  tied  above  and 
below  the  wound  in  it  (Fig.  155).     If  the  vein  is  found  injured  too 

*  If  venous  hfemorrliage  persist,  the  opening  in  the  vessel  should  be  secured  with 
a  chromic-gut  ligature,  or  a  pair  of  Spencer  Wells's  forceps  left  in  situ  (p.  868). 


876  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

severely  for  a  laterally  applied  ligature,  and  requires  ligature  in  the 
ordinary  way,  the  patient  or  the  friends  must  be  prepared  for  the 
imminent  need  of  amputation. 

(b)  If  a  punctured  wound  lies  in  the  line  of  the  artery  (p.  870), 
and  if  much  blood  has  been  lost,  the  main  trunk  is  probably  injured, 
and  the  question  will  arise,  if  the  bleeding  has  ceased,  whether  to  cut 
down  upon  the  artery  or  .to  trust  to  pressure.  Mr.  Cripps  (Did.  of 
Surg.,  vol.  i.  p.  525)  advises  that  if  the  wound  be  in  the  upper  part  of 
the  thigh,  "  the  surgeon  may  enlarge  the  wound  with  a  good  prospect 
of  finding  the  wounded  vessel  without  an  extensive  or  prolonged 
operation.  If  the  wound  be  in  the  lower  half  of  the  thigh,  owing  to 
the  greater  depth  of  the  artery,  and  the  possibility  of  its  being  the 
popliteal  which  is  wounded,  the  search  is  rendered  far  more  severe 
and  hazardous,  and  it  should  not  be  undertaken  until  a  thorough 
trial  of  pressure  has  proved  ineffectual." 

The  following  mode  of  applying  pressure  is  taken  from  Mr.  Cripps 
(loc.  supra  cit.).'^  1  would  also  refer  my  readers  to  the  account  of 
jjunctured  wound  of  the  palm  given  at  p.  36  of  this  work. 

The  main  vessel  being  controlled  above  the  foot  and  leg  should  be 
carefully  strapped  from  the  toes  to  the  knee,  and  a  bandage  then  car- 
ried from  the  toes  up  to  the  wound,  and  then,  avoiding  this,  up  to  the 
groin,  where  it  is  secured,  spica  fashion,  over  a  pad  on  the  main 
artery.  The  limb  is  then  laid  on  a  long  back  splint  with  a  foot-piece 
and  secured  to  this  in  an  elevated  position.  The  wound  being  cleansed 
and  dusted  with  iodoform,  a  graduated  compress  (p.  36)  is  then 
fastened  over  it.  Two  rectal  bougies  are  then  applied  in  tlie  course 
of  the  artery,  above  and  below  the  wound,  outside  the  bandage  which 
surrounds  the  limb,  so  as  to  keep  these  segments  of  vessel  empt3^ 
Two  well  padded  lateral  splints  are  then  secured  with  straps  and 
buckles  to  the  thigh.  Morphia  must  be  given  as  freely  as  is  judi- 
cious.f 

2.  Haemorrhage  from  Stump  after  Amputation  in  Lower  Third  of 
Thigh  or  Knee. — If  clearing  away  the  clots  and  disinfecting  the 
stump,  followed  by  well  adjusted  pressure,  and,  this  failing,  trying  to 

*  Mr.  Cripps's  account  will  be  found  nnder  the  heading  of  the  treatment  of  second- 
ary hseniorrhage  from  the  fenioial.  He  draws  attention  to  the  instriictiveness  of  the 
literature  of  this  subject,  as  it  proves  not  only  that  many  cases  have  l)een  successfully 
treated  by  pressure  from  the  first,  but  that  both  life  and  limb  have  been  saved  by 
pressure  after  the  surgeon  has  failed  to  find  the  artery  in  the  wound,  or  after  tying  the 
iliac  in  vain. 

t  Mr.  Cripps  advises  that  tlie  limb  sliould  be  slightly  raised  on  a  pillow,  and  partly 
bent  at  the  knee  and  thigh.  The  toes  should  be  left  exposed  that  their  condition  may 
be  watched. 


LIGATURE   OF    FEMORAL    IN    HUNTEr's    CANAL.  877 

find  the  bleeding  point  in  the  flaps,  do  not  suffice,  the  artery  must  be 
tied  above.* 

Line  and  Guide  (p.  870). 

Relations  :  In  Front. 

Saphena  vein. 

Skin;  fasciae;  sartorius;  aponeurosis  between 
vastus  internus  and  adductors. 

Outside.  Inside. 

Vastus  internus  ;  vein  (slight!}'')-  Adductor  loiigus  and  magnus. 

Femoral  artery  in  Hunter's  canal. 

Behind. 
Femoral  vein  (especially  above). 

Operation  (Fig.  154). — The  knee  and  hip  being  flexed,  and  the 
limb  abducted  and  rotated  outwards,  the  surgeon,  seated  comfortably 
on  the  inner  side  of  the  limb,  makes  an  incision  31  inches  long  in  line 
of  the  artery  in  the  middle  third  of  the  thigh.f  The  skin,  superficial 
and  deep  fascise,  being  divided,  and  the  saphena  vein  drawn  to  one  side 
with  a  strabismus  hook,  and  any  of  its  branches  divided  between 
double  chromic-gut  ligatures,  the  sartorius  is  identified  by  the  direction 
of  its  fibres  and  drawn  to  the  inner  side.  The  canal  is  next  opened  by 
dividing  the  aponeurotic  roof,  and  the  artery  or  its  pulsation  felt  for. 
This  vessel  will  be  found  closely  connected  with  its  vein,  which  lies 
behind  it,  while  the  saphenous  nerve  crosses  it  from  without  inwards. 
The  artery  being  most  carefully  cleansed  all  round,  the  ligature  may 
be  passed  from  either  side,  as  is  fmnd  most  convenient. J 

Causes  of  Failure  after  Ligature  of  the  Femoral. 

1.  Gangrene. 

*  I  would  again  refer  my  readers  to  Mr.  Cripps's  article  {loc. supra  cit.,  p.  526).  He 
points  out  that  a  decision  between  opening  the  flaps  or  ligaturing  the  main  vessel  higii 
up  nnist  depend  on  the  amount  of  union,  and  that  if  the  flaps  must  be  opened  and 
the  vessel  sought  for  before  there  is  mucli  firm  union,  as  in  the  first  fortnigiit,  a  director 
should  be  used  rather  than  a  l<nife,  and  that  if  the  vessel  is  found,  its  soft  condition 
will  require  very  gentle  tying. 

f  This  incision  must  not  be  made  too  low  down.  Its  centre  should  correspond  to  tlie 
centre  of  the  tliigh. 

X  Much  difiiculty  will  be  met  witii  in  tying  the  femoral  artery  in  Hunter's  canal  un- 
less the  line  of  the  artery  (p.  870)  is  strictly  followed.  A  common  mistake  is  to  make 
the  incision  too  far  out,  thus  exposing  tlie  fibres  of  the  vastus  internus,  which  run 
downwards  and  outwards,  instead  of  tiiose  of  the  sartorius,  which  run  downwards  and 
inwards  (Smith  and  Walsham,  ^Ltn.  of  Oper.  Sure/.,  p.  83).  Erichsen  {Surc/ery,  vol.  ii. 
p.  250),  who  gives  as  the  line  of  the  artery,  one  drawn  from  a  point  exactly  midway 
between  the  anterior  superior  spine  and  sympliysis  pubis  to  the  most  prominent  part  of 
the  internal  condyle,  insists  on  the  need  of  making  the  incision  a  finger's  breadth  in- 
ternal to  this.     Tlie  line  given  above  (p.  870)  will  be  found  sufficiently  internal. 


878  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

2.  Secondary  Haemorrhage. — If  pressure  fail,  an  attempt  must  he 
made  to  re-tie  the  vessel,  and,  this  not  succeeding,  the  limb  must  be 
amputated. 

3.  Suppuration  of  the  Sac  of  an  Aneurism. — This  is  very  rare. 

4.  Recurrent  Pulsation  in  the  Aneurism.  The  premature  softening 
of  catgut,  especially  in  a  septic  wound,  must  always  be  remembered 
as  a  possible  cause  of  this.  Pressure  failing,  the  artery  may  be  tied 
lower  down. 

5.  A  very  rare  complication  is  the  formation  of  an  aneurism  at  the 
seat  of  ligature. 

AMPUTATION  THROUGH  THE  THIGH. 

Practical  Points  in  Amputation  of  the  Thigh. — As  the  soft 
parts  behind  are  more  bulky  than  those  in  front,  and  as  it  is  desirable 
to  place  the  bone  as  near  as  possible  in  the  centre  of  the  soft  parts,  the 
back  of  the  thigh,  in  the  case  of  a  bulky  limb,  may  be  supported  by 
the  hand  of  an  assistant  during  the  first  introduction  of  the  knife  to 
form  the  anterior  flap  (Skey).  Amputation  should  always  be  per- 
formed as  low  down  as  possible,  not  only  to  avoid  shock  and  to  secure 
as  long  a  stump  as  possible  for  the  artificial  limb,  but  also  to  secure  as 
much  as  possible  of  the  rectus  femoris.  This  muscle  is  the  sole  agent 
by  which  the  thigh  is  put  forward  in  stepping.  Its  division  does  not 
preclude  the  retention  of  its  office,  as  it  acquires  a  sufficient  adhesion 
to  the  material  of  the  stump  to  answer  every  useful  purpose  as  ah  agent 
in  the  fiexion  of  the  thigh  on  the  pelvis,  though  that  of  extension  of 
the  leg  be  destroyed  (Skey,  Oper.  Surg.,  p.  391). 

Different  Methods. — The  following  five,  Avhich  will  give  ample 
choice,  will  alone  be  described  here ;  the  first  is  especially  recom- 
mended : 

I.  Mixed  Antero-posterior  Flaps  and  Circular  Division 

of  the  Muscles. 
II.  Antero-posterior  Flaps  by  Transfixion. 

III.  The  Circular  Method. 

IV.  Rectangular  Flaps. 
V.  Lateral  Flaps. 

I.  Mixed  Antero-posterior  Flaps  and  Circular  Division  of 
the  Muscles. — By  the  term  mi-xed  is  meant  an  anterior  flap  of  skin 
and  fascia"  raised  from  without,  and  a  posterior  one  made  by  transfixion. 
The  anterior  is,  wherever  practicable,  made  the  longer  of  the  two. 

This  method  has  the  following  great  advantages:  (1)  The  longer 
anterior  flap  falls  well  over  the  bone  and  thus  keeps  the  scar  behind  ; 
(2)  Being  raised  from  without  inwards,  it  can  be  taken  from  the  neigli- 
borhood  of  the  knee-joint  and  patella;    (3)  It  is  a  most  expeditious 


AMPUTATION    THROUGH    THE    THIGH. 


879 


method,*  almost  as  quick  as  that  by  double  transfixion  flaps  ;  (4)  It 
is  suited  to  all  cases,  save  perhaps  those  of  very  muscular  thighs,  where 
the  surgeon  should  be  careful  to  take  only  part  of  the  muscles  behind 
as  he  transfixes,  or  else  should  raise  his  posterior  flap  also  from  with- 
out inwards  ;  (5)  It  gives  good  drainage. 

Operation. — The  femoral  artery  being  controlled  with  an  Esmarch's 
bandage,t  the  limb  being  brought  over  the  edge  of  the  table  and  sup- 
ported by  an  assistant,  who  has  bandaged  the  damaged  or  diseased  part 
to  give  his  hands  a  firmer  grip,  and  to  prevent  their  becoming  septic ; 

Fig.  156. 


The  knife  should  have  been  inserted  here  from  the  inner  side. 

the  opposite  ankle  being  tied  to  the  table,  and  the  parts  duly  cleansed, 
the  surgeon,  standing  to  the  right  side  of  the  limb  to  be  removed,  places 
his  left  index  and  thumb  on  either  side  of  the  limb,  at  the  level  where 
he  intends  to  saw  the  bone,!  and  sinking  the  point  of  his  knife  through 
the  skin  just  below  the  former  and  rather  below  the  centre  of  the  outer 
or  inner  aspect  of  the  limb  as  the  case  may  be,  carries  it  rapidly  down 
for  about  42  inches,  and  then  sweeps  it  across  the  limb  with  a  broad, 
not  pointed,  convexity,  and  carries  it  up  along  the  side  nearest  to  him 
as  far  as  his  thumb.  This  flap  is  then  quickly  dissected  up  of  skin 
and  fasciie,  and  the  knife,  being  sent  across  the  limb,  behind  the  bone, 
cuts  a  posterior  flap  almost  as  long  as  the  anterior,  the  knife  being  used 
with  a  rapid  sawing  movement,  and  driven  at  first  straight  down  paral- 
lel with  the  bone,  and  then  sharply  brought  out  through  the  skin. 


*  As  in  railway  and  other  accidents. 

f  If  tlie  surgeon  is  aniputating  very  high  up,  the  method  given  in   the  account  of 
amputation  at  the  hip-joint  (pp.  845-6)  may  be  used. 

X  The  finger  and  thiunb  should  not  be  shifted  till  the  anterior  flap  is  marked  out. 


880  OPERATIONS   ON    THE   LOWER    EXTREMITY. 

The  flaps  being  held  out  of  the  way  with  the  surgeon's  left  hand  * 
the  soft  parts  around  the  femur  are  next  severed  with  a  circular  sweepj 
the  knife  being  used  as  at  -p.  100,  till  the  bone  is  exposed,  when  one 
more  firm  sweep  divides  the  periosteum.^ 

The  saw  is  now  placed  with  its  heel  on  the  bone  and  drawn  towards 
the  operator  once  or  twice  with  firm  pressure  so  as  to  make  one  groove 
and  one  only.  With  a  few  sharp  sweeps  the  bone  is  next  severed,  care 
being  taken  to  use  the  saw  lightly  for  fear  of  splintering  the  linea  as- 
pera,  and  to  use  the  whole  length  of  the  instrument.  At  this  time 
the  limb  must  be  kept  steady  and  straight,  the  assistant  neither  raising 
it,  which  will  lock  the  saw,  nor  depressing  it,  which  will  splinter  the 
femur  when  this  is  partly  divided. 

If  the  surgeon  decide  to  make  his  posterior  flap  also  of  skin  and 
fascia?,  he  must  have  the  limb  raised,  and  first  looking  over  and  then 
stooping  down,  marks  out  a  skin  flap  about  n  the  length  of  the  anterior  ; 
this  is  then  dissected  up,  and  the  operation  completed  as  before. 

In  addition  to  the  femoral  vessels,  the  anastomotica,  and  descending 
branch  of  the  external  circumflex,  some  muscular  branches  will  require 
attention ;  and  one  of  these  last  may  give  some  trouble  from  its  posi- 
tion close  to  the  bone  in  contact  with  the  linea  aspera.§ 

In  amputations  of  the  thigh  accompanied  by  grave  shock,  no  need- 
less time  should  be  lost  in  looking  for  vessels,  save  the  femoral  and 
any  other  large  branch  which  can  be  seen.  Firm  bandaging  and  rais- 
ing the  stump  will  suffice.  It  is  well  to  partially  relieve  the  tightness 
of  the  bandaging  in  a  few  hours  by  nicking  them.  Very  few  sutures 
should  be  used  in  these  cases  of  shock,  or  in  those  where  the  soft  parts 
are  sinus-riddled. 

II.  Transfixion  Flaps. — Advantage. — Great  rapidity.  Disadvan- 
tages.— Those  given  at  p.  61,  on  a  large  scale.  This  method  may  be 
used  Avhere  great  speed  is  needed,  as  in  a  double  amputation  after  a 
railwa}^  accident,  or  where  many  wounded  require  attention,  as  after 
a  great  battle.     It  is  also  adapted  to  the  wasted  muscles  of  a  patient 

*  And  also  pressed  firmly  upwards,  so  as  to  enable  the  saw  to  be  applied  as  high  up 
as  possible.     If  the  limb  is  bulky  an  assistant  must  help  here. 

f  Ihis  requires  really  forcible  use  of  the  knife,  the  muscles  behind  the  bone  tending 
to  be  pushed  before  the  knife  rather  than  divided  by  it. 

J  This  final  cut  should  be  a  little  above  the  base  of  the  flaps,  in  order  that  the  sawn 
femur  may  lie  well  buried  in  soft  parts. 

§  The  following  points  deserve  attention  in  tying  ihe  femoral  vessels:  (])  Not  to 
include  the  saphenous  nerve;  (2)  the  tendency  of  the  vessels  to  slip  up  if  the  point  o*^ 
their  division  fiasses  through  Hunter's  canal ;  (3)  if  the  vessels  are  atheromatous  they 
must  not  be  tied  too  tightly.  A  carbolized  silk  ligature,  not  too  fine,  shoidd  be  em- 
ployed now,  and  care  should  be  taken  to  include  a  little  of  the  soft  parts  to  prevent 
the  ligature  cutting  through. 


AMPUTATION    THROUGH    THE   THIGH. 


881 


who  has  long  suffered  from  some  chronic  disease  of  knee  or  leg,  but 
even  here  it  is  inferior  to  the  mixed  method. 

Operation.— The  preliminarj'^  steps  given  at  p.  879  being  taken, 
the  surgeon,  standing  to  the  right  side  of  either  limb,  with  his  left 
index  and  thumb  marking  the  site  of  his  intended  bone-section,  raises 

Fig.  157. 


(Fergussoii.) 


Avith  his  hand  the  soft  parts  on  the  front  and  sides  of  the  thigh,  and 
sends  his  knife  across  the  limb  in  front  of  the  femur.  The  knife 
should  be  entered  well  below,  so  as  to  get  as  large  an  anterior  flap  as 
possible,  and,  at  its  entry,  should  be  pushed  a  little  upwards  so  as  to 
go  easily  over  the  bone.  An  anterior  flap  is  then  cut  4  to  4*  inches 
long,  with  a  broadly  curving  almost  square  extremity,  and  not  too 
thin  at  its  edge.  This  being  raised  by  the  surgeon  or  an  assistant, 
the  knife  is  now  passed  behind  the  bone  and  a  posterior  flap  cut  of 
the  same  length  ns  the  anterior,  the  making  of  this  flap  being  some- 
what facilitated  by  drawing  the  soft  parts  on  the  back  of  the  limb 
away  from  the  bone. 

If  the  limb  be  very  bulky  the  knife  should  be  kept  well  away  from 
the  bone,  especially  behind  it,  and  not  as  at  p.  880;  thus  the  more 
superficial  muscles  only  will  be  included  in  the  posterior  flap. 

Both  flaps  being  retracted,  the  remaining  soft  parts  are  severed  with 
circular  sweeps,  and  the  rest  of  the  operation  completed,  as  at  p.  880, 
but  with  this  diff'erence,  that  here  there  will  be  more  need  of  trim- 
ming some  of  the  soft  parts  clean  and  square.* 


*  While  dresser  to  the  late  Mr.  Poland,  I  once  saw  the  femoral  vessels  split  for 
about  3^  inches  by  his  rapid  hands.  Tliis  amputation  of  the  thigh  was  his  last  opera- 
tion at  Guy's  Hospital.  He  was  even  then  facing  with  quiet  bravery  the  bronchitis 
which,  a  very  few  days  later,  ended  his  life. 

50 


882  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

III.  The  Circular  Method.— I  may  here  state  briefly  wliy  this 
method  is,  nowachiys,  considovcd  inferior,  botli  in  the  tiiigh  and  else- 
where, to  tliat  l)y  flaps.     In  saying  this,  it  is  not  denied  that  in  many 

Fig.  1-58. 


Circular  iinii>ut!iti()n  of  the  Ihigli  to  show  the  greater  retraction  of  the  muscles  behind. 

cases  stumps  by  the  circular  method  are  fully  equal  to  those  by  flaps; 
indeed,  in  many  it  is  impossible  to  tell,  in  later  years,  which  method 
has  been  employed.  On  the  Avhole,  however,  the  flap-method  lias  the 
following  advantages  :  (1 )  It  is  most  generally  applicable — <?.(/.,  in 
parts  not  circular  and  at  the  joints.*  (2)  By  it  the  surgeon  can  better 
adapt  his  skin  covering  to  his  needs — e.g.,  when  the  skin  is  less 
available  on  one  aspect  of  the  limb  than  on  another.  (3)  There  is 
less  risk  of  a  conical  stump ;  and  (4)  of  a  cicatrix  adherent  to  the 
bone.  The  great  advantage  of  the  circular  method — viz.,  that  the 
vessels  and  nerves  are  cut  square,  and  that,  thus,  the  former  retracting 
more  easily,  fewer  need  securing,  while  there  is  less  risk  of  bulbous 
ends  forming  on  the  latter,  is  attained  by  the  mixed  method  of  skin 
flaps  and  circular  division  of  the  muscles  as  at  p.  879.t 

The  circular  method  is  only  to  be  adopted  here  in  the  case  of  the 
lower  third  of  wasted  thighs,  or  in  those  of  young  subjects.  Even 
here  the  greater  tendency  of  the  posterior  muscles  to  retract  must  be 
met  by  cutting  them  about  f  inch  longer  than  those  in  front. 

While  this  operation  is  for  the  above  reasons  not  recommended  in 
practice,  it  may  be  made  use  of  in  tlie  lower  third  of  the  thigli,  in  the 
cases  mentioned  above.  On  the  dead  subject  the  student  who  has 
not  had  a  chance  of  performing  it  u]>on  the  arm,  may  make  use  of 
it  here. 

Operation. — As  this  method  has  been  described  in  detail  at  p. 


*  To  these  it  may  be  added  that  the  circular  method  is  not  adapted  to  a  case  where 
the  skin  is  matted  to  the  subjacent  muscles. 

f  One  more  advantage  of  the  flap  method  is  the  greater  rapidity,  especially  when 
transfixion  is  employed,  though  this,  in  these  days  of  anaesthetics,  is  only  of  importance 
in  a  few  cases. 


AMPUTATION    THROUGH    THE   THIGH.  883 

100,*  it  will  be  onl}'  briefly  given  here.  The  preliminaries  are  those 
already  given.  The  surgeon  standing  to  the  right  of  the  limb,  the 
assistant  who  stands  on  the  opposite  side  to  him,  but  nearer  the  trunk 
draws  up  the  skin  with  both  hands.  The  surgeon,  stooping  a  little, 
passes  his  knife  first  under  the  limb,  then  above,  across,  and  so  around 
it  till  by  dropping  the  knife  vertically  the  back  of  the  instrument  looks 
towards  him,  while  its  heel  rests  on  that  side  nearest  to  him.  He  then 
makes  a  circular  sweep  around  the  thigh,  this  being  aided  by  the 
assistant  who  has  charge  of  the  limb  rotating  it  so  as  to  make  the  soft 
parts  meet  the  knife.  The  surgeon  then  taking  hold  of  the  edge  of  the 
incision  dissects  up  a  cuft'-like  flap,  about  4->  inches  in  length,  cutting 
it  of  even  thickness  all  round  the  limb.  This  flap  is  then  folded  back, 
and  the  remaining  soft  parts  divided  with  circular  sweeps  of  the  knife. 
In  doing  this,  the  greater  contraction  of  the  hamstring  muscles  must 
be  remembered,  and  these  muscles  cut  rather  longer  than  those  in 
front.  Care  must  be  taken,  if  it  is  thought  needful,  after  making  the 
circular  sweeps,  to  free  the  bone  higher  up,  and  so  to  secure  its  being 
well  buried  in  the  soft  parts,  and  not  to  prick  the  already  divided 
femoral  vessels  which  lie  in  close  proximity  to  the  femur  in  the  lower 
third. 

IV.  Rectangular  Flaps  of  Mr.  Teale. — This  method  is  fully 
described  below.  It  is  not  recommended  here  as  it  is  expensive, 
involving  division  of  the  bone  nearer  to  the  trunk  than  other  methods. 
(1)  Owing  to  the  bulkiness  of  the  long  anterior  flap,  it  is,  here,  especi- 
ally difhcult  to  fold  and  adjust  it  at  the  conclusion  of  the  operation, 
and  still  more  so  to  keep  it  adjusted  if  primarv  union  fails.  (3)  Its 
chief  advantage,  that  of  keeping  the  end  of  the  bone  well  buried,  and 
of  cutting  the  vessels  and  nerves  clean  and  square,  are  also  sufficiently 
attained  by  the  other  flap  methods  already  given,  especially  the  mixed 
method  (p.  880). 

V.  Lateral  Flaps. — This  method  has  certain  grave  objections  here. 
(1)  The  sawn  femur,  tilted  upwards  by  the  ilio-psoas,  is  very  liable  to 
press  against  the  upper  angle  of  the  flops,  and  to  come  through  at  this 
spot  and  necrose.  (2)  If  this  does  not  take  place,  the  bone  often 
adheres  to  the  cicatrix  here,  while  the  flaps  hang  down  and  away  from  it. 

It  should  only  be  made  use  of  when  no  other  method  is  available,  as 
in  a  case  where,  owing  to  the  condition  of  the  soft  parts,  flai)s  can 
only  be  got  by  making  one  long  external  and  a  short  internal,  or  vice 
versa. 


*  If  it  be  objected  that  the  plan  here  given  of  turning  up  a  ciiff-like  flap  is  likely  to 
lead  to  slougliing,  I  would  refily  that  tills  is  not  so  in  tiiese  days  of  antiseptic  surgery. 
If  sloughing  is  dreaded,  a  little  more  time  should  be  taken  in  dissecting  up  a  thin  laytr 
of  muscle,  so  as  to  secure  tlie  deep  fascia,  and  thus  a  better  vascular  supj)ly. 


884  OPERATIONS   ON   THE    LOWER   EXTREMITY. 

Operation. — This  and  its  modification  of  antero-external  and 
postero-internal  fiaps  are  fully  descriljed  at  p.  879. 

AMPUTATIONS    IMMEDIATELY    ABOVE    THE    KNEE- 
JOINT  (Figs.  159-165). 

Methods. 

i.  Garden's  (Figs.  159,  160,  161). 

ii.  Gritti's  Trans-condyloid  (Figs.  162,  164). 

iii.  Stokes's  Supra-condyloid,  an  important  modification  of  the 
above  (Figs.  163,  165). 

All  the  above,  but  especially  the  two  latter,  possess  the  following 
advantages  (which  they  share  with  amputation  through  the  knee- 
joint)  over  amputation  through  the  thigh,  viz. : 

1.  The  patient  can  bear  his  weight  in  walking  on  the  face  of  his 
stump,  thus,  he  is  not  compelled  to  take  his  bearing  from  the  tube- 
rosity of  the  ischium,  or  to  walk  as  if  he  had  an  ankylosed  hip-joint 
(Stokes),  as  is  the  case  after  amputation  of  the  thigh,  where  the  stump 
is  ever  liable  to  be  fretted  by  the  slightest  pressure  on  it. 

2.  Very  good  power  of  adduction  over  the  artificial  limb  remains. 
Every  operating  surgeon  must  have  noticed  how  badly  off  a  patient  is 
in  this  respect  after  an  ordinary  amputation  through  the  thigh.  By 
these  methods  the  adductors  are  left  almost  intact,  even  to  part  of  the 
strong  vertical  tendon  of  the  adductor  magnus,  the  result  being  that 
the  balance  between  the  adductors  and  abductors  of  the  thigh  remains 
practically  undisturbed,  and  the  patient  when  walking  has  none  of 

Fig.  159. 


(Garden). 

that  difficulty  (which  is  seen  after  thigh  amputations)  of  bringing  the 
limb  which  he  has  swung  forwards,  in  again  under  the  centre  of 
gravity.* 

3.  The  medullary  canal  is  not  opened  ;  on  this  account  there  is  less 
risk  of  necrosis  and  osteo-myelitis  if  the  stump  becomes  septic. 

4.  There  is  less  shock,  because  (a)  the  limb  is  removed  farther  from 

*  The  importance  of  the  preservation  of  the  quadriceps  extensor,  given  by  the 
Stokes-Grritti  method,  need  only  be  alluded  to. 


AMPUTATIONS    IMMEDIATELY    ABOVE    THE    KNEE-JOIXT.         885 

the  trunk,  (6)  the  muscles  are  divided  not  through  their  vascular  bel- 
lies, but  tlirough  their  tendons. 

i.  Garden's  Amputation  (Figs.  159, 160,  161). 

Advantages. — This  valuable  amputation  has  some  points  in  common 
\\ith  Svme's  amputation  at  the  ankle-joint.     In  both  the  bone-section 

Fig.  160. 


(Garden). 

is  made  not  through  a  medullary  canal,  but  through  vascular  quickly 
healing  cancellous  tissue ;  in  both,  the  skin  reserved  for  the  face  of  the 
stump  has  been  used  to  pressure,  though  not  equally  so,  for  the  skin 
preserved  in  the  ankle  amputation  is  thick  and  callous,  in  the  other 
thinner  and  more  sensitive. 

Sir  J.  Lister*  thus  recommends  this  amputation  :  "  This  operation, 
Avhen  contrasted  with  amputation  in  the  lower  third  of  the  thigh,  pre- 
sents a  remarkable  combination  of  advantages.  It  is  less  serious  in 
its  immediate  effects  upon  the  system, because  a  considerably  smaller 
quantity  of  the  body  is  removed,  and  also  because  the  limb,  being 
divided  where  it  consists  of  little  else  than  skin,  bone,  and  tendons, 
fewer  bloodvessels  are  cut  than  when  the  knife  is  carried  through  the 
highly  vascular  muscles  of  the  thigh ;  the  popliteal  and  one  or  two 
articular  branches  being,  as  a  general  rule,  all  that  require  attention, 
so  that  loss  of  blood  is  much  diminished.  In  the  further  progress  of 
the  case  the  tendency  to  protrusion  of  the  bone,  which  often  causes 
inconvenience  in  an  amputation  through  the  thigh,  is  rendered  com- 
paratively slight  by  the  ample  extent  of  the  covering  provided,  and 
also  by  the  circumstance  that  the  divided  hamstrings  slip  up  in  their 
sheaths,  so  that  the  posterior  muscles  have  comparatively  little  power 
to  produce  retraction.  The  superiority  of  the  operation  is  equally 
conspicuous  as  regards  the  ultimate  usefulness  of  the  stump,  which, 
from  its  great  length,  has  full  command  of  the  artificial  limb,  while  its 
extremity  is  well  calculated  for  sustaining  pressure,  both  on  account 
of  the  breadth  of  the  cut  surfiice  of  the  bone  divided  through  the  con- 
dyles, and  from  the  character  of  the  skin  habituated  to  similar  treat- 

*  System  of  Surgery,  vol.  iii.  p.  705. 


886 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


ment  in  kneeling.  Considering,  therefore,  that  this  procedure  can  he 
substituted  for  amputation  of  the  thigh  in  the  great  majority  of  cases 
both  of  injury  and  disease  formerly  supposed  to  demand  it, '  Garden's 
operation '  must  be  regarded  as  a  great  advance  in  surgery."* 

Disadvantages. — The  chief  of  these  is  the  sloughing  of  the  long  ante- 
rior flap  which  may  occur,  "in  spite  of  faultless  operating,"  especially 
if  the  skin,  of  which  it  chiefly  consists,  has  been  damaged  by  injury 
or  disease,  or  if  the  patient  l)e  old  or  weakly,  thus  leading  to  an 
adherent,  twider  scar,  and  a  useless  stump. 

Operation. — According  to  its  introducer  this  amputation  consists 
in  removing  a  rounded  flap  from  the  front  of  the  joint  (Figs.  159, 160, 
161),  dividing  everything  else  straight  down  to  the  bone,  and  sawing 
this  slightly  above  the  plane  of  the  muscles. 

The  operator  standing  on  the  right  side  of  the  limb,  seizes  it,  between 
his  left  forefinger  and  thumb,  at  the  spot  selected  for  the  base  of  the 
flapf  and  enters  the  point  of  his  knife  close  to  his  finger,  bringing  it 


Fig    101. 


Fig.  162. 


Gritti's  trans-condyloid  section  of  the  femur,  leaving 
a  surface  mucli  too  large  for  the  sawn  patella  to  fit. 

round  through  the  skin  and  fat  below  the  patella  to  the  spot  pressed 
by  his  thumb,  then  turning  the  edge  downwards  at  a  right  angle  with 
the  line  of  the  limb,  he  passes  it  through  to  the  spot  where  it  first 
entered,  cutting  outwards  through  everything  behind  the  bone.  The 
flap  is  then  reflected,  and  the  remainder  of  the  soft  parts  divided 


*  Other  advantages  given  by  Mr.  Garden  are,  the  favorable  position  of  tiie  stump 
for  dressing  and  drainage;  its  painlessness,  the  chief  nerves  being  cut  high  up  out  of 
reach  of  pressure;  and  the  cicatrix  being  drawn  clear  of  the  point  of  the  bone,  and 
out  of  reach  of  pressure. 

f  This  corresponds  with  the  upper  border  of  the  patella,  the  limb  being  extended. 
The  lower  margin  comes  down  to  the  tubercle  of  the  tibia,  as  in  Fig.  159.  See  also 
Brit.  Med  Journ ,  1864,  vol.  i.  p.  416. 


AMPUTATIONS    IMMEDIATELY    ABOVE   THE    KNEE-JOINT. 


887 


straight  down  to  the  bone;  the  muscles  are  then  slightly  cleared  up- 
wards, and  the  saw  applied  "  through  the  base  of  the  condyles."  The 
projecting  part  of  the  femur  may  be  rounded  off.  Where  there  is  any 
doubt  about  the  vitality  of  the  large  anterior  flap,  a  short  posterior 
one  should  be  made,  the  anterior  one  thus  not  needing  to  be  so  long 
(Fig.  161). 

ii.  Gritti's  Trans -condyloid,  iii.  Stokes's  Supra-condyloid 
Amputation  (Figs.  162,  163,  164, 165). 

For  fuller  information  on  the  above  amputations  I  would  refer  my 
readers  to  a  paper  I  contributed  to  the  Gai/^s  Hosp.  Reports,  vol.  xxiii. 
p.  211, 1878.  The  objections  to  amputation  through  the  knee-joint, 
whether  by  a  long  anterior,  "br  long  posterior  flap  are  given  at  p.  891. 
Amputation  through  the  knee-joint  by  lateral  flaps  gives  excellent 
results,  but  in  this  method  the  incisions  are  carried  into  the  leg  below 
the  tibial  tubercle;  in  the  two  amputations  mentioned  above  this 
point  is  not  trenched  upon,  and  every  surgeon  knows  that  after  a 
severe  compound  fracture  of  the  leg,  an  inch  or  two  more  or  less  of 
damage  to  the  soft  parts  in  the  upper  third  of  the  leg  makes  a  most 
important  diff'erence  as  to  where  he  can  amputate. 

The  two  methods  are  often  confused.  Between  them  there  is  this 
all-important  difference:  in  Gritti's,  the  section  of  the  femur  is  made 


Fig.  163. 


Fig.  164. 


Stokes's  supra-condyloid  section  of  tlie  femur,  The  flaps  in  Gritti's  trans-condyloid  amputation, 
leaving  a  surface  much  more  easily  fitted  by  the  showing  the  patella  hitched  and  requiring  force  to 
sawn  patella.  adapt  it  to  the  femur,  which  is  now  too  long  as  well 

as  too  broad. 


through  the  condyles  ;  in  Stokes's,  at  least  2  inch  above  iheu\.    In  other 
words,  the  one  operation  is  trans-,  the  other  supra-condyloid. 

On  this  point  great  stress  has  been  laid,  and  very  rightly,  by  Sir  W. 
Stokes,  and  a  comparison  of  the  two  operations  will  convince  every 
one  that  he  is  correct.  If  the  section  of  the  femur  be  made  through 
the  condyles  (Figs.  162,  164)  the  sawn  patella  will  not  fit  down  into 
place.     It  will  either  be  drawn  up  altogether  on  to  the  front  of  the 


888 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


femur,  or  else  Avill  project  forwards,  somewhat  like  the  half-open  lid 
of  a  box,  at  an  angle  to  the  broad  sawn  surface,  which  is  also  too  large 
for  it  to  cover,  and  across,  and  off  which  it  is  liable  to  be  shifted  by 
the  contraction  of  the  quadriceps,  if  it  has  been  found  possible  to  get 
it  into  place.  To  effect  this,  an  amount  of  force  will  be  required  which 
is  almost  certain  to  I'esult  in  bruising  of  the  cut  periosteum  on  the 
edge  of  the  femur,  and  consequent  necrosis.  If,  on  the  other  hand, 
the  saw  is  made  to  pass  ?  inch  above  the  condyles  (Fig.  163.),  the  patella 
will  fall  readily  into  place,  it  will  cover  more  completely  the  now 
smaller  sawn  surface  of  the  femur,  and  will  remain  easily  in  situ  here, 
the  flaps  when  brought  together  presenting  the  appearance  shown  in 
Fig.  165. 

Operation. — An  Esmarch's  bandage  being  applied,  the  limb 
brought  over  the  edge  of  the  table  and  supported,  and  the  opposite 
one  secured  out  of  the  way  the  surgeon  standing  to  the  right  of  the 
limb,  with  his  left  index  and  thumb  marking  the  base  of  his  flap, 
makes  an  incision  commencing  (on  the  left  side)  an  inch  above  and 
rather  behind  the  external  condyle,  carried  vertically  downwards  to  a 
point  opposite  to  the  tibial  tubercle,  then  broadly  curved  across  the  leg 
and  carried  upwards  to  a  point  opposite  to  that  from  which  it  started. 
This  flap,  having  been  dissected  upwards,  together  with  the  patella 

Fig.  165. 


Appearance  of  the  stump  in  a  Stokes-Gritti's  amputation, 
come  easily  into  place. 


The  patella  has 


(after  severing  the  ligamentum  patelUe)  a  posterior  flap  is  cut  nearly 
as  long  as  the  anterior.  This  may  be  effected  in  one  of  two  ways, 
either  by  the  surgeon  looking  over  and  then  stooping  a  little  (the  limb 
being  now  raised),  next  drawing  the  knife  from  without  inwards 
across  the  popliteal  space,  thus  marking  out  and  then  dissecting  up  a 
skin  flap,  or  by  transfixing  and  cutting  the  flap  from  within  outwards. 
Of  the  two  I  prefer  the  first;  the  latter  is  the  speedier,  but  less  suited 
to  bulky  limbs.  The  flaps  being  retracted,  the  soft  parts  are  cut 
through  with  a  circular  sweep  i  inch  above  the  articular  surface  of  the 
femur,  the  bone  is  then  sawn  through  here,  and  the  limb  removed. 


REMOVAL   OF    EXOSTOSIS    FROM    NEAR    ABDUCTOR   TUBERCLE.       889 

The  postei-ior  surface  of  the  patella  is  next  removed  with  a  metacarpal- 
or  small  butcher's-saw.  This  last  step  is  the  only  difficult  one  in  the 
operation,  owing  to.  the  mobility  of  the  bone :  it  will  be  facilitated  by 
an  assistant  with  both  his  hands  everting  and  projecting  the  under 
surface  of  the  anterior  flap,  so  as  to  make  the  patella  stand  out 
from  it. 

The  vessels — popliteal,  one  or  two  articular  and  the  anastomotic — 
having  been  secured,  drainage  is  provided,  and  the  flaps  are  brought 
together  with  numerous  points  of  suture,  save  at  the  angles  (Fig.  165). 

Where  the  flaps  are  cut  of  proper  length  and  the  femur  is  sawn  at 
the  proper  height,  it  is  quite  exceptional  for  the  patella  not  to  ride 
easily  in  situ.  If  there  seem  any  doubt  on  this  point,  or  if  the  patient 
is  very  muscular,  additional  security  may  be  given — (a)  By  passing 
sutures  of  chromic  gut  or  carbolized  silk  between  the  tissues  on  the 
under  surfiice  of  the  anterior  flap,  at  the  edges  of  the  patella,  and  the 
soft  parts  in  the  posterior  flap  (avoiding  the  vicinity  of  the  large  ves- 
sels) ;  (b)  by  wiring  or  pegging  the  bones ;  (c)  by  dividing  the  rectus 
muscle  on  the  under  surface  of  the  anterior  flap.  Of  these,  wiring  or 
pegging  is  the  best ;  the  pegs  must  be  scrupulously  clean.  An  ordinary 
bradawl,  also  rendered  aseptic,  will  be  found  quite  as  efficient  as  a  drill. 

REMOVAL  OF  AN  EXOSTOSIS  FROM  NEAR  THE 
ADDUCTOR  TUBERCLE.* 

As  these  growths  are  by  no  means  uncommon  in  adolescents,  this 
operation  will  be  briefly  described  here.  Aseptic  excision  has  now 
replaced  any  other  operation  such  as  subcutaneous  fracture. 

Operation. — The  parts  being  thoroughly  cleansed,  the  knee  is 
flexed  so  as  to  bring  down  the  synovial  membrane,  and  the  limb 
placed  on  its  outer  side.  A  free  incision,  about  3j  inches  long,  is  made 
over  the  growth  down  to  the  vastus  internus,  and  any  superficial  ves- 
sels attended  to.  The  muscular  fibres  are  then  cleanly  cut  through,! 
and  the  bluish-gray  cartilage  which  caps  the  swelling  now  comes  into 
view. I  Any  muscular  branches  being  now  carefully  secured,  and  the 
wound  sponged  dry,  the  cut  vastus  is  pulled  aside  by  retractors,  and 
the  growth  being  thoroughly  exposed  it  is  shaved  off  with  an  osteotome 
or  chisel,  leaving  exposed  cancellous  tissue.  A  little  iodoform  is  dusted 
in,  and  drainage  provided  by  a  tube  or  large  horsehair  drain,  passed 
from  the  wound  to  the  most  dependent  spot  on  the  inner  side,  the 

*  This  account  will  serve  for  the  removal  of  other  exostoses — e.g.,  that  met  with  at 
the  deltoid  insertion. 

f  This  is  more  likely  to  conduce  to  primary  union  than  tearino;  tiiera  through  with 
a  director. 

X  Any  synovia-like  fluid  now  escaping  comes  probably  from  a  bursa  over  the  growtli, 
not  from  the  joint. 


890  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

dressing-forceps  passing  under  the  muscle  and  being  cut  down  upon  by 
counter-puncture,  where  they  project  under  the  skin.  The  muscular 
fibres  are  then  united  with  chromic  gut,  cut  short,  and  the  wound 
closed  with  separate  sutures.  Strict  aseptic  precautions  are  taken 
throughout  to  secure  primary  union.  The  limb  should  be  kept  abso- 
lutely quiet  on  a  back  splint,  and  a  Martin's  bandage  worn,  later,  for 
a  short  time. 

UNUNITED  FRACTURE!  OF  THE  FEMUR. 

The  large  number  of  failures  after  operations  for  this  condition  are 
well  known.  The  difficulties  which  may  be  present  during  and  after 
these  operations  are  very  considerable ;  amongst  them  sufficient  ex- 
posure of  the  fragments,  and  keeping  the  wound  aseptic,  are  most 
prominent. 

Operation. — On  the  whole,  the  introduction  of  pegs  having  been 
less  successful,  sub-periosteal  resection  of  the  fragments  is  indicated 
here.*  This  is  especially  so  in  long-standing  cases,  where  other 
methods  have  failed,  where  there  is  very  little  attempt  at  repair,  where 
an  artificial  joint  exists,  or  where,  after  a  severe  injury,  necrosis,  atrophy 
of  the  fragments,  and  fibrous  union  have  followed. 

The  operation  of  resection  should  always  be  performed  with  strict 
aseptic  precautions,  otherwise  the  risks  of  suppuration,  erysipelas, 
osteo-myelitis,  and  pyjemia,  owing  to  the  very  free  incision  required, 
the  exposure  of  cancellous  tissue  and,  perhaps,  of  the  medullary  canal, 
are  considerable. 

The  limb  having  been  rendered  bloodless,  if  practicable,  with 
Esm arch's  bandages,  the  fracture  is  exposed  by  a  free  incision,  5  to  6 
inches  long,  on  the  outer  side  of,  and  going  down  to,  the  bone.  The 
periosteum  is  next  most  carefully  detached  from  the  ends  of  the  frag- 
ments, and  a  thin  layer  of  bone,  about  a  i  inch  in  thickness,  removed 
from  each.  To  facilitate  the  resection,  the  fragments  may  be  thrust 
out  of  the  wound,  or,  after  the  removal  of  the  periosteum,  dragged  out 
and  steadied  with  sequestrum-forceps  before  the  saw  is  applied.  The 
soft  parts  must  be  protected  with  spatula)  and  retractors  wliile  the 
ends  of  the  bone  are  removed  with  a  narrow-bladed  saw.  The  frag- 
ments are  now  brought  into  exact  apposition,  and  to  facilitate  this  it 
may  be  necessar}^  to  divide  adhesions  or  to  remove  any  intervening 
fibrous  or  fibro-cartilaginous  material,  or  a  sequestrum.  The  ends  are 
now  to  be  drilled,  the  drill  being  entered  on  the  superficial  surface  of 

*  Sir  J.  Lister  has  recorded  {Brit.  Med.  Journ.,  August  26,  1871)  the  case  of  an 
ununited  extra-capsular  fracture  of  the  femur  in  a  man  aged  forty-five,  where,  eighteen 
months  after  the  injury,  he  cut  down  ou  the  fragments,  witli  antiseptic  precautious,  and 
gouged  them,  the  fracture  being  then  finally  put  up.  Recovery  was  complete,  the  man 
walking  well. 


AMPUTATION    THROUGH    THE    KNEE  JOINT.  891 

each  fragment,  and  then  made  to  project  in  the  centre  of  the  medullary 
canal.  The}'  are  next  held  together  hy  passing  very  stout*  silver  wire 
through  the  drill-holes  and  twisting  this  upu  If  the  wire  is  to  be  removed 
three  or  four  half-twists  or  two  complete  twists  should  be  sufficient- 
If  the  surgeon  prefer  he  may  hammer  it  down,  in  situ,  having  made 
three  half-twists  and  cut  the  ends  short.  See  the  remarks,  p.  79. 
Sutures  are  best  dispensed  with  so  as  to  allow  of  free  drainage.  The 
after-treatment  is  thai  of  a  compound  fracture. 


CHAPTER  III. 

OPERATIONS  INVOLVING  THE  KNEE-JOINT. 

AMPUTATION  THROUGH  THE  KNEE- JOINT.  —  EXCI- 
SION OP  THE  KNEE-JOINT.  —  ARTHREOTOMY  OF 
THE  KNEE-JOINT.  — WIRING  THE  PATELLA.  — RE- 
MOVAL OF  LOOSE  CARTILAGES  FROM  THE  KNEE- 
JOINT. 

AMPUTATION   THROUGH    THE   KNEE-JOINT, 

Chief  Methods. 

I.  By  Lateral  Flaps.  II.  By  Long  Anterior  and  Short 
Posterior  Flaps.  Of  these  the  first  is  far  the  superior.  The  great 
ol)jection  to  the  second  is,  that  in  order  to  get  sufficient  covering  to 
fall  readily  over  the  large  condyles,  a  long  anterior  flap  must  be  cut ; 
as  this  must  reach  2  incheg  below  the  tibial  tubercle,  a  good  deal  of 
its  blood-supply  comes  from  below — e.g.,  the  recurrent  tibial  must  be 
cut  off,  and  the  flap  is  thus  liable  to  slough.  This  risk  is  much 
diminished,  and  the  blood-supply  better  equalized,  by  the  method  of 
lateral  flaps. 

I.  Amputation  by  Lateral  Flaps.— This,  the  method  of  Dr. 
Stephen  Smith,t  Avas  brought  before  English  surgeons  by  Mr.  Bryant.J 
The  femoral  being  controlled,  the  limb  supported  over  the  edge  of  the 
table,  and  slightly  flexed,  the  surgeon  standing  on  the  right  side  of 
either  limb  marks  out  two  broad  lateral  flaps  as  follows :  His  left 
index  finger  and  thumb  being  placed,  the  former  over  the  centre  of 
the  head  of  the  tibia,  the  latter  at  the  corresponding  point  behind, 

*  About  yV  incli  in  thickness,  so  as  to  withstand  the  strain  of  the  muscles  of  an 
adult  thigh. 

+  Neiv  YorJc  Journ.  of  Meet,  September,  18 ')2;  Amer.  Joiirn.  Med.  Sci.,  January, 
1870. 

X  Med.-Chir.  Trans.,  vol.  Ixix.  p.  163- 


892 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


opposite  the  centre  of  the  joint,  he  marks  out  (in  the  case  of  the  right 
limb)  an  inner  flap  by  an  incision  which,  commencing  close  to  the 
thumb,  is  carried  down  along  the  back  of  the  limb  for  about  3^ 
inches,  and  then  curves  upwards  and  forwards  across  the  inner  aspect 
of  the  leg,  till  it  ends  in  front  just  below  the  index  finger.*  The  knife 
not  being  taken  off",  a  similar  flap  is  then  shaped  from  the  outer 
side,  but  in  the  reverse  direction.  Dr.  S.  Smith  calls  attention  to  the 
following  points :  In  making  these  flaps,  they  should  be  cut  broad 

Fig.  166. 


Amputation  through  knee-joint  by  lateral  flaps.    (Bryant.) 

enough  to  secure  ample  covering  for  the  condyles,  and  the  inner  one 
should  be  made  additionally  full  as  the  internal  condyle  is  longer 
than  the  external.  The  flaps  should  be  at  least  82  inches  long,  if  of 
equal  length.  They  consist  of  skin  and  fascit^e.  When  they  have 
been  raised  as  far  as  the  line  of  the  articulation  the  ligamentum  pa- 
tellas  is  then  severed,  allowing  the  patella  to  go  upwards.  The  soft 
parts  around  the  joints  are  then  cut  through  with  a  circular  sweep, 
and  the  leg  removed.  In  doing  this,  the  limb  being  flexed  to  relax 
the  parts  and  facilitate  opening  the  joint,  the  semilunar  cartilages 
will  very  likely  be  found  closely  encircling  the  condyles  of  the  femur. 
Mr.  Bryant,  in  the  paper  already  quoted,  and  Dr.  Brinton,t  as  long 
ago  as  1872,  have  strongly  advised  that  the  semilunar  cartilages 
should  be  left  in  sita  by  severing  the  coronary  ligaments  which  tie 
them  to  the  tibia.  They  thus,  in  Dr.  Brinton's  words,  form  "  a  cap, 
fitted  on  the  end  of  the  femur,  which  preserves  all  the  fascial  rela- 


*  Dr.  S.  Smith  begins  his  incision  about  1  incli  below  the  tubercle  of  the  tibia,  and 
carries  it  up  rather  higher  behind — viz.,  to  the  centre  of  the  articulation.  It  will  be 
found  easier  to  open  the  joint  and  to  detach  the  semilunar  cartilages  from  the  tibia  by 
making  the  incision  as  recommended  above. 

t  Pliilad.  Med.  Times,  December  28,  1872. 


EXCISION    OF   THE    KNEE-JOINT.  893 

tions,  eventually  prevents  retraction,  and  guards  against  the  projection 
of  the  condyles." 

Mr.  Pick's*  modification  of  the  above  operation  is  twofold — viz., 
(1)  He  begins  his  incision  higher  up — i.e.,  at  the  upper  border  of  the 
patella;  and  (2)  he  removes  the  patella.  This  last  would  appear 
likely  to  run  the  risk  of  damaging  the  blood-supply. 

II.  By  a  Long  Anterior  and  a  Short  Posterior  Flap.— The 
position  of  the  patient  and  the  surgeon  being  as  at  p.  891,  the  latter 
with  his  left  index  and  thumb  on  either  side  of  the  interval  between 
the  femur  and  tibia,  enters  his  knife  (in  the  case  of  the  right  limb) 
just  below  the  finger  and  internal  condyle,  carries  it  straight  down 
along  the  inner  side  of  the  leg  till  it  reaches  a  spot  2  inches  below  the 
tibial  tubercle,t  then  squarely  across  the  leg  till  -it  reaches  a  corre- 
sponding point  well  back  upon  the  outer  side,  and  thence  up  to  a 
point  just  below  his  thumb,  or  to  the  external  condyle.  This  flap  is 
then  dissected  up,  containing  the  patella,  as  thickly  as  jjossible,  and 
almost  rectangular  in  shape,  anything  like  pointing  of  its  lower  end 
being  most  carefully  avoided,  as  certain  to  lead  to  sloughing. 

This  flap  being  raised,  a  posterior  flap  is  made  about  two-thirds  the 
length  of  the  first,  as  at  p.  888,  either  by  dissection  from  without 
inwards,  or  by  transfixion  after  disarticulation. 

EXCISIONj   OF  THE  KNEE-JOINT. 

Indications. — A.  For  Disease.     B.  Injury. 

A.  (i.)  Pulpy.     Tubercular  knee. 

This  condition  being  the  most  frequent  indication  for  excision  of 
the  knee,  calls  for  most  careful  consideration  of  the  following  points : 

(1)  Safety  and  Amount  of  Risk. — Sir  J.  Lister's  treatment,  by  re- 
moving sepsis,  has  rendered  excision  of  the  knee  absolutely  safe  in 
properly  selected  cases.  No  surgeon  who  is  familiar  with  careful 
antiseptic  treatment  and  excision  of  the  knee  will  say  that  the  above 
is  too  strong  a  statement.§     Excision   here  contrasts  very  sharply 

*  Med.  Soc.  Proc ,  vol.  vii.  1884,  p.  134. 

f  Mr.  Pollock  [Med.-Chir.  Trans.,  vol.  liii.  p.  20)  advises  that  the  anterior  flap 
should  reacii  "quite  5  inches  below  the  patella."  It  is  difficult  to  see  how  sloughing 
can  be  avoided  here,  so  much  of  the  blood  to  this  very  long  flap  coming  from  below 
and  being  of  necessity  cut  off. 

X  Tills  operation  is  contrasted  with  arthrectomy  of  the  knee  at  p.  909. 

I  I  may  perhaps  say  here  that  I  have  excised  the  knee  fifty-seven  times.  Of  these 
three  died  of  eflects  of  the  operation,  one  (mentioned  below)  from  shock,  another  (also 
mentioned  below)  from  threatening  gangrene,  and  another  from  surgical  scarlet  fever. 
This  ciiild  was  moved,  during  n)y  absence  from  town,  into  an  empty,  chilly  ward  ;  the 
eruption  became  dusky  and  then  suppressed  ;  coma,  followed  by  death,  ensued.  Four 
have  been  submitted  to  amputation,  making  good  recoveries.     This  number  would 


894  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

with  the  same  operation  at  the  hip,  from  the  much  greater  facilities 
for  getting  away  all  the  disease  at  the  time,  and  for  getting  at  and 
examining  the  wound  later,  together  with  the  greater  ease  with  which 
the  wound  here  is  kept  aseptic. 

(2)  Age. — Here  the  operation  has  to  be  considered — (a)  as  a  substi- 
tute for  amputation  ;  {h)  as  a  substitute  for  the  expectant  treatment. 
While  excision  may  be  successfully  employed  at  any  age  up  to  thirty, 
and  even  occasionally  in  older*  patients,  I  consider  the  most  favora- 
able  years  to  be  from  about  fifteen  to  twenty.  Before  fifteen,  and 
particularly  before  ten,  we  have  especially  to  consider  the  effect  of 
the  ojieration  on  the  growth  of  the  bone;  after  twenty  we  have  more 
and  more  to  consider  the  condition  of  the  patient,  the  state  of  the 
viscera,  general  vitality,  etc.  I  would  ask  my  reader's  careful  atten- 
tion to  these  points — (1)  that  the  chief  growth  of  the  femur  takes 
place  at  its  lower  end  (p.  858) ;  (2)  that  by  fifteen,  and  still  more  by 
seventeen,  the  growth  of  the  bone  is  largely  completed.  It  follows 
from  the  above  remarks  that  in  young  subjects  especially  before  ten, 
as  little  of  the  bones  as  possible  should  be  removed,f  that  repeated 
slices,  rather  than  one  small  one,  should  be  made,  and  that  gouging 
may  largely  replace  the  saw  (p.  905). 

(3)  Rayik  of  Life. — Excision  of  the  knee  being  almost  unknown  in 
private  practice,  it  is  needless  to  remark  that  this  account  of  the 
operation  refers  almost  entirely  to  hospital  patients.  Let  me  briefly, 
though  imperfectly,  depict  the  usual  fate  of  these  patients  with  pulpy 
knee  if  not  excised  early.  Bandied  about  from  one  out-patient  room  to 
another,  treated  more  or  less  imperfectly  with  splints  and  strapping, 
frequently  recommended  for  admission  that  they  may  obtain  that 
''  rest "  Avhich  can  nowhere  else  be  carried  out,  at  last  "  the  dresser  for 
the  Aveek,"  or  surgeon,  takes  pity  on  the  case  and  it  is  admitted. 
With  what  result?  As  soon  as  the  inflammation  has  subsided  and 
the  'pain  has  ceased,  the  child  is  thought  to  be  occupying  a  bed  which 
can  be  better  employed  for  clinical  teaching,  and  after  a  few  weeks' 
rest  in  bed,  is  turned  out  again,  perhaps  in  plaster-of-Paris  or  a 
Thomas's  splint.*  A  little  later,  in  the  rough-and-tumble  life  of  the 
courts  and  alleys  of  our  large  towns,  the  joint  is  wa'enched,  and  the  good 
gained  is  all  undone.  Suppuration  now  sets  in  at  one  or  more  points 
of  the  pulpy  tissue,  sinuses  form,  the  ends  of  the  bone  become  carious, 
and  the  condition  of  the  joint  from  the  now  advanced  stage  of  the 
disease,  and  its  probably  septic  condition,  is  rendered  far  less  favor- 
probably  have  been  five,  as  a  patient,  aged  fifty-three,  whose  knee  had  been  excised 
for  disorganization  after  osteo-arthsitis  and  whom  I  had  advised  to  submit  to  ampu- 
tation, went  out  able  to  walk  a  little  with  a  stick,  but  with  two  sinuses. 

*  See  the  remarks  on  osteo-arthritis. 
t  See  the  foot-note,  p.  905. 


EXCISION    OF   THE    KNEE.  895 

able  for  any  operation  than  it  was  at  an  earlier  stage.  Speaking 
briefly,  believing,  as  I  do,  that  in  this  rank  of  life  excision  will  be 
needed  in  nine  cases  out  of  ten,  I  am  of  opinion,  most  distinctly, 
that,  as  soon  as  a  pnlpy  condition  is  declared,  excision  or  erasion  (or 
rather  both,  combined,  p.  899)  should  be  performed  while  the  state 
of  the  joint  and  the  general  condition  of  the  jjatient  are,  alike, 
favorable. 

(4)  J^alue  of  tlie  Limb. — This  quxdlo  vexata  of  tliirty  years  ago  is 
now  largel}''  settled.  Ver}'-  few  will,  nowadays,  be  found  to  dispute 
Avhich  is  most  serviceable,  a  limb  though  much  shortened  with  a 
natural  foot,  or  an  artificial  leg,  especiall}'^  of  the  kind  supplied  to 
hospital  patients  after  amputation  of  the  thigh.  On  this  subject  some 
remarks  of  Mr.  Holmes  (Surg.  Dis.  of  Children,  p.  497),  may  be  quoted. 
"  Even  if  we  allowed  that  a  patient,  after  successful  excision  of  the 
knee,  could  only  walk  as  fast  and  as  far  as  some  with  a  good  artificial 
liml)  after  amputation,  this  would  still  leave  the  operation  of  excision, 
in  my  mind,  far  the  superior  one,  since  the  former  patient  can  do  by 
his  own  force,  without  any  preparation  and  without  an}^  expense, 
what  the  latter  can  only  do  by  the  aid  of  the  instrument-maker.  I 
need  hardly  say,  however,  that  this  is  a  gross  understating  of  the 
case.  A  patient  after  excision  of  the  knee  can  often  walk  nearly  as 
fost  and  nearly  as  far  as  he  could  before.  The  patient  after  amputa- 
tion of  the  thigh,  however  well  the  case  may  have  done,  can  rarely 
V)ear  the  fatigue  of  carrying  the  artificial  limb  many  miles  together, 
nor  can  there  be  any  reasonable  comparison  of  the  agility  of  the  two 
— at  least  in  those  cases  where  the  foot,  after  excision,  comes  nearly 
on  to  the  ground,  and  is  in  good  position."  As  to  those  cases  where 
the  limb  is  flail-like,  and  its  growth  seriously  arrested,  I  would  point 
out  that  they  should  hardly  ever  occur,  with  the  impi'oved  treatment 
of  wounds,  the  greater  facilities  with  which  a  stiff  apparatus  of  a 
simple  kind  can  nowadays  be  supplied,  our  more  exact  knowledge  of 
the  epiphyses,  and  the  substitutes  for  the  saw  which  are  to  our  hands 
in  the  shape  of  sharp  spoons  (p.  898).  I  may  also  refer  my  readers 
to  Sir.  W.  Fergusson's  Hunterian  Lectures,  Lecture  VI.,  and  his  argu- 
ments in  favor  of  a  much-shortened  limb  over  any  artificial  one. 

(5)  Condition  of  the  Patient. — I  may  refer  my  readers  to  the  remarks 
on  this  point  on  excision  of  the  hip,  p.  859.  There  is  the  same  need 
here  for  examining  for  any  evidence  of  lardaceous  disease,  or  tuber- 
cular mischief,  elsewhere,  and  to  remember  how  latent  and  insidious 
these  may  be.  Bone  mischief  elsewhere  is  not  necessarily  prohibi- 
tive. Three  out  of  my  fifty-seven  cases  (p.  893)  had  had  spinal  dis- 
ease, well-marked  bosses  remaining  in  all.  Each  of  them  made  an 
excellent  recovery.  Strumous  disease  of  the  tarsus  existed  in  two 
others,  and  was  cured  by  the  time  the  knee  was  well.     In  two,  disease 


896  OPERATIONS   ON   THE    LOA\'ER   EXTREMITY. 

of  the  hip  coexisted  on  the  same  side ;  in  one  the  limb  had  eventu- 
ally to  be  removed  by  a  Furneaux  Jordan's  amputation,  tlie  child  re- 
covering;  in  tlie  otlier  (the  disease  being  on  the  opposite  side)  the 
knee  after  a  trans-patellar  excision  did  excellently,  the  hip-disease 
l)eing  cured  by  rest. 

(6)  Stage  of  the  Disease. — I  have  already  shown  (p.  894)  that  I  am 
a  strong  advocate  for  early  excision  in  hospital  cases,  believing  that, 
with  the  usual  treatment,  short  of  this,  pulpy  disease  goes  on,  as  a 
rule,  inveterately  from  bad  to  Avorse.  But  in  early  life  excellent  re- 
sults may  be  obtained  in  advanced  cases,  with  sinuses  and  caries,  if 
only  all  the  diseased  and  septic  material  is  got  away. 

(ii)  Threatening  disorganization  of  the  knee,  with  caries,  after  pyae- 
mia, rheumatic  fever,  etc. 

(iii)  Osteo-arthritis. — Where  one  joint  only  is  affected,  and  the 
patient  is  not  past  middle  life,  excision  gives  good  results.  The  sur- 
geon must  be  prepared  for  sawing  very  dense  bones. 

(iv)  Ankylosis. — I  think  excision  should  be  abandoned  here  for  the 
far  better  operation  of  dividing,  with  aseptic  precautions,  the  union, 
with  an  osteotome  introduced  first  on  one  side  and  then  on  the  other, 
and  worked  forwards  under  the  patella,  and  skin,  and  backwards  as 
far  as  the  popliteal  artery  allows.  If  this  fail,  a  double  osteotomy  of 
the  femur  and  tibia  should  be  performed  rather  than  excision,  an 
operation  which,  in  the  case  of  true  bone  ankylosis,  is  liable  to  be 
severe,  prolonged,  and  to  leave  a  large  wound,  and,  in  the  case  of 
young  subjects,  to  lead  to  further  shortening  of  a  limb  already 
atrophied  and  weakened  from  disease.  As  I  shall  not  have  space  again 
to  refer  to  this  matter  of  ankylosis  of  the  knee,  I  would  strongly  urge 
caution  in  rapidly  and  completely  straightening  a  knee-joint  which 
has  long  been  the  seat  of  a  bony  ankylosis  in  a  bad  position.  My 
attention  Avas  drawn  to  this  matter  in  a  painful  Avay  about  five  years 
ago.  A  girl  of  nineteen  had  been  admitted  under  my  care  with  bony 
ankylosis  of  the  knee  at  a  right  angle,  dating  to  disease  seventeen  years 
before.  Finding  that  I  was  unable  to  materially  improve  the  position 
by  subcutaneously  sawing  through  the  bony  union,  I  excised  the  joint 
and  straightened  it  completely.  The  foot  and  leg  remaining  cold,  an 
ana?sthetic  was  given  next  day,  and  the  liml)  put  up  flexed.  The 
mischief  was,  however,  done.  The  coldness  remained,  all  pulsation 
in  the  tibials  stopped,  and  gangrene  evidently  threatening,  the  thigh 
was  amputated,  the  patient  sinking  afterwards.* 

*  Just  after  this  another  London  surgeon  published  a  very  similar  case.  SufB- 
cient  attention  lias  not  been  drawn  to  this  matter.  It  would  have  been  much  wiser  on 
my  part,  with  such  dense  and  old-standing  ankylosis,  not  to  liave  attempted  complete 
straightening  at  once,  but  to  have  straightened  partly  with  an  osteotome  at  first,  and 
then  to  have  completely  rectified  the  position  later.  I  have  adopted  this  mode  suc- 
cessfully since,  on  a  much  older  patient,  with  almost  as  much  contraction. 


EXCISION    OF   THE    KNEE.  897 

Post-mortem,  a  layer  of  osteophytes  was  found  on  the  posterior 
border  of  the  tibia  projecting  backwards,  and  it  was  evident  that  over 
these,  when  the  hmb  was  straightened,  the  popliteal  vein,  a  very 
small  one,  had  been  stretched  and  closed.  Another  most  serious  risk 
of  at  once  straightening  a  contracted  knee  is  tetanus,  from  stretching 
of  the  contracted  poi^liteal  fascia  and  the  popliteal  nerves. 

(v)  Old,  Neglected  Infantile  Paralysis. — Excision  of  the  knee  seems 
to  me  to  be  perfectly  justifiable  here,  with  a  view  of  giving  a  firm 
support  in  the  case  of  a  limb  useless  from  its  flail-like,  distorted 
state.  I  speak  here  of  hospital  cases,  which  furnish  those  miserably 
crippled  lives  which  are  still  seen  from  time  to  time  going  the  rounds 
of  the  hospitals.  I  have  tried  it  in  one  case,  where  the  result  is  good, 
the  knee  having  healed  with  one  dressing,  but  the  child  is  still 
under  treatment  for  the  paralytic  tnlipes  of  the  ankle,  and  paralysis 
of  one  upper  extremity.  I  followed  in  this  my  old  friend  G.  A. 
Wright,  of  Manchester,  who  in  the  abstract  of  cases  treated  in  the 
Pendlebury  Hospital,  1884,  records*  the  result  of  a  case — a  girl,  aged 
fourteen — in  which  he  had  successfully  excised  the  knee  and  ankle  in 
such  a  case. 

B.  Ix.TURY. — Here  such  injuries  as  those  from  gunshot  and  those 
from  a  lacerated  wound  or  a  compound  fracture,  must  be  considered 
separately. 

1,  Gunshot. — "  The  results  of  the  excisions  of  the  knee-joint,  per- 
formed during  the  late  civil  war,  whether  the  operations  were  primary, 
intermediary,  or  secondary,  were  not  very  encouraging,  forty-four  of  the 
fifty-four  cases  in  which  the  issues  were  ascertained  having  terminated 
fatally,  a  m'ortality  of  81.4  per  cent,  exceeding  the  mortality  of  the  am- 
putations of  the  thigh  (53.8)  by  27.6  per  cent."  (Otis).!  Sir  T.  Long- 
more;{;  lays  down  these  definite  rules :  "  From  all  the  experience  which 
has  been  gained  regarding  gunshot  wounds  in  which  the  knee-joint  has 
been  opened,  especially  if  the  surfaces  of  the  bone  have  escaped  damage, 
as  may  occasionally  happen  with  modern  narrow  rifle-bullets,  and  even 
in  other  cases  where  one  of  the  bones  has  been  fissured,  or  partial  fract- 

*  The  knee  excised  in  1883  was,  a  year  and  a  half  later,  sound,  straight,  and  well. 
The  ankle,  remaining  very  weak,  was  excised,  December,  1884,  by  a  transverse  inci- 
sion. The  bones  were  soft  and  fatty,  and  conid  be  cut  with  a  knife.  The  tibia  and 
astragalus  were  joined  with  stout  silver  wire,  tlie  ends  being  twisted  and  knocked  down  ; 
the  tendons  were  sutured  with  catgut.  The  wound  was  healed  in  less  than  a  month. 
Measurement  on  January  12,  188o,  showed  2\  inches  shorttning  as  the  result  of  the 
two  excisions;  the  ankle  excision  did  not  ai)i)ear  to  have  percejJtibly  shortened  the 
limb,  while  there  is  1}  inch  less  shortening  than  before  the  excision  of  the  knee.  No 
doubt  the  limb  had  grown  with  the  increased  power  and  use  in  it.  February,  1885: 
The  child  could  now  walk  across  the  room  upon  the  leg. 

t  Loc.  svpra  cit.,  p.  419. 

X  Syst.  of  Surg.,  vol.  i.  p.  565. 

57 


898  OPERATIONS   ON   THE   LOWER    EXTREMITY. 

ure  has  occurred,  provided  early  immobilization  of  the  injured  parts 
can  be  secured,  antiseptic  treatment  carried  out,  and  the  general  sur- 
roundings are  sufficiently  hygienic,  it  may  now  be  laid  down  as  a 
rule  that  conservative  treatment  ought  to  be  adopted.  When,  however, 
the  circumstances  under  which  the  wounds  have  been  inflicted  are 
such  that  the  precautionary  measures  and  modes  of  treatment  men- 
tioned cannot  be  put  into  practice,  when  the  patients  are  liable  to  be 
moved  frequently  or  to  long  distances  hurriedly  and  without  adequate 
protection,  or  when  the  joint  is  not  only  penetrated,  but  the  surround- 
ing coverings  are  much  lacerated,  or  the  bones  are  comminuted  and 
the  fragments  completely  detached,  the  sacrifice  of  the  limb  by  am- 
putation above  the  joint  is  the  only  measure  calculated  to  afford  a  fair 
promise  of  safety  of  life  to  the  patient." 

2.  Injuries  other  than  Gunshot. — Excision  is  rarely  practicable  here. 
A  very  careful  consideration  of  the  local  and  general  conditions 
present  is  needful.  Amongst  the  former,  damage  limited  to  the  artic- 
ular surfaces,  but  little  splintering  of  the  shafts  of  the  bones,  an  intact 
condition  of  the  soft  parts  behind  the  joint  are  absolutely  essential. 
No  less  important  is  it  to  weigh  the  more  general  points  connected 
with  the  patient — viz.,  his  age  not  reckoned  by  years  onl}^,  the  condi- 
tion of  his  viscera,  and  liis  habits;  all  these  points  are  attended  to  in 
the  account  of  "The  Treatment  of  Compound  Fractures,"  given 
later  on. 

Operation.* — The  more  I  perform  this  operation,  the  more  do  I 
feel  the  truth  of  the  words  of  Prof.  Bruns,  of  Tubingen,  that,  while 
formerly  its  chief  object  was  to  remove  all  dead  bone,  it  should  now 
be  considered  of  chief  importance  to  remove  all  the  granulation- 
material  that  can  possibl3'  be  got  away,  and  that  the  surgeon  should 
not  content  himself  with  snipping  away  all  he  can,  leaving  the  rest 
to  caseate  or  become  scar-tissue  if  it  will,  but  pursue  it  with  the  same 
earnest  aim  of  extermination  as  he  would  in  the  case  of  malignant 
disease,  I  would  not  by  the  above  seem  to  speak  slightingly  of  the 
value  of  securing  healthy  and  correctly  sawn  surfaces  of  bone,  as 
on  these  largely  depends  firm  ankylosis  and  a  sound  and  useful 
limb,  but  I  would  insist  on  the  fact  that  such  surfaces  are  secured  in 
vain  if  pulpy  material  is  allowed  to  remain,  and  that  it  is  not  as  yet 
sufficiently  recognized  that  other  instruments — e.g.^  sharp  spoons  and 
scissors  curved  on  the  flat — are,  to  the  full,  as  useful  as  the  saw. 

Before  the  time  of  the  excision,  any  flexion  of  the  knee  should  be 
corrected  as  far  as  possible  by  careful  weight  extension.  A  knee 
should  never  be  excised  while  flexed.     Such  a  step  will  not  only  be 

*  Before  and  thronghoiit  an  excision  of  the  knee  the  operator  should  bear  in  mind 
the  following  points:  (I)  To  remove  every  atom  of  the  disease;  (2)  to  secure  good 
drainage;  (3)  to  leave  the  bones  in  good  position;  (4)  to  ensure  absolute  immobility 
afterwards;  (5)  to  watch  for  and  at  once  attack  any  relapse. 


EXCISION    OF    THE    KNEE.  899 

liable  to  lead  to  removing  bone  needlessly  in  order  to  straighten  it, 
but  stretching  the  contracted  deep  fascia  and  nerves  may  lead  to 
tetanus  (p.  896),  The  risk  of  gangrene  has  also  been  already  men- 
tioned (p.  896). 

The  parts  being  duly  cleansed,  and  an  Esmarch's  bandage*  applied 
at  mid-thigh,  the  limbf  is  brought  over  the  edge  of  the  table,  flexed, 
and  held  by  an  assistant  as  in  Fig.  169. 

From  the  moment  of  commencing  the  operation  to  its  very  close 
the  surgeon  must  bear  in  mind  the  inveteracy  of  tubercular  pulpy 
material  (malignancy  would  probably  not  be  too  strong  a  word),  and 
in  his  endeavors  to  extirpate  the  disease  completely,  both  in  the  soft 
parts  and  in  the  bones,  his  operation  must  combine  the  operations  of 
erasion  and  excision. J 

The  following  modes  of  exposing  the  joint  will  be  given  here : 

A.  Transverse,  Removing  the  Patella. 

B.  Transverse,  through  the  Patella. 

C.  The  Semi-lunar  Flap  (lately  recommended  by  Mr,  Barker, 
and  attributed  by  him  to  Moreau). 

A.  Transverse,  Removing  the  Patella  (Fig.  167).— This,  the 
older  method,  is  still  resorted  to  by  those  surgeons  who,  like  Mr, 
Howse,  believe  that,  if  the  patella  is  retained  a  most  serious  risk  is 
run  of  leaving  behind  pulpy  material  which  will  require  removal 
later  on  under  less  favorable  circumstances,  and,  this  failing,  may 
lead  to  amputation. 

The  surgeon,  standing  on  the  left§  side  of  the  diseased  knee  (the 
opposite  limb  being  tied  to  the  table),  makes  an  incision  right  across 
the  joint  from  the  back  of  one  condyle  to  that  of  the  other.||     This 

*  Some  object  to  the  bandage  as  needless  and  as  likely  to  lead  to  troublesome  ooz- 
ing after  the  operation.  This  may  be  met  by  firm  pressure  and  even  bandaging  on 
of  the  dressings,  so  as  to  distribute  any  oozing  evenly  throughout  them.  If  an 
Esmarch's  bandage  is  not  applied,  the  bleeding  during  the  operation  interferes  with  the 
removal  of  diseased  tissues,  requires  constant  pressure  to  arrest  it,  and  taxes  the 
patient's  resources  considerably.  Its  use  meets  another  risk,  v.-hich  is  possibly  hypo- 
thetical, and  that  is,  it  renders  impossible  the  general  diffusion  of  tubercular  material 
by  the  cut  veins  and  lymphatics.  Two  Esmarch's  bandages  must  not  be  applied  if 
there  is  any  risk  of  rupturing  a  pulpy  capsule,  or  where  the  capsule  has  given  way 
and  septic  sinuses  exist. 

f  Before  the  operation  the  area  of  incision  should  be  thoroughly  cleansed  ;  the  foot 
and  lower  leg  should  be  well  wrapped  up  in  cotton  wool,  a  heel-stirrup  being  applied 
if  there  is  likely  to  be  a  sore  heel. 

X  If  operations  for  pulpy  knee  are  resortefl  to  at  an  earlier  stage  iu  hospital  patients 
the  bones  will  less  and  less  need  interfering  with. 

^  This  position  renders  it  much  easier  for  him  to  saw  the  femur  and  tibia. 

II  Beyond  this  spot  the  incision  should  not  go,  for  fear  of  wounding  the  internal 
saphena  vein.  This  would  lead  to  troublesome  a'dema  of  the  foot  and  leg,  and,  if  the 
wound  should  become  septic,  might  bring  about  septic  phlebitis  and  pyaemia. 


900 


OPEUATIOXS    ON    THE    LOWER    EXTREMITY. 


incision  passes  over  the  lower  part  of  the  patella  and  divides  the 
lateral  ligaments  at  once.  The  soft  parts  being  then  dissected  up  for 
2  inches  above  the  patella,  so  as  to  expose  the  supra-patellar  pouch, 
deep  incisions  are  made  above  and  below  the  patella,  which  is  then 
removed  and  the  joint  opened.* 

If  the  patella  is  ankylosed  to  the  condyles,  it  must  be  removed  by 
a  blunt  elevator,  aided  by  a  narrow  saw,  or,  better,  by  an  osteotome 
and  mallet.  No  violence  should  be  used  in  opening  a  joint  partially 
ankylosed,  for  the  epiphyses  may  easily  be  separated  from  the  shaft, 
especially  in  a  child. 

B.  Transverse,  through  the  Patella  (Fig.  1G8).— This  method, 
by  preserving  the  patella  and  the  insertion  of  the  quadriceps,  coun- 


FiG.  167. 


Fig.  168. 


Trans-patellar  excision. 

terbalances  the  flexing  action  of  the  hamstringsf  at  the  same  time. 
It  was  brought  before  the  notice  of  English  surgeons  by  Mr.  Golding 
Bird  in  a  case  which  he  brought  before  the  Clinical  Society  (Clin.  Soc. 

*  I  invariably,  when  raising  tlie  flap  of  soft  parts  in  an  excision  of  the  knee,  how- 
ever performed,  slit  them  up  by  a  vertical  incision,  going  to  tlie  upper  limit  of  the 
siipra-pateliar  pouch,  so  as  to  expose  fully  all  its  folds  and  recesses.  Unless  this  is 
done,  pulpy  material  is  very  easily  left  behind,  and,  later  on,  breaking  down,  leads  to 
oedema,  persistent  sinuses,  giving  way  of  the  pouch  and  escape  of  [)ulpy  suppuration 
amongst  the  adductors  and  into  the  vicinity  of  the  femoral,  and  perforating  vessels, 
where  it  is  impossible  to  eradicate  it,  amputation  being  eventually  called  for. 

t  P.  908. 


EXCISION    OF   THE    KNEE.  901 

Trails.,  vol.  xiv.  p.  82).  In  the  nine  cases  in  which  I  have  employed 
it,  it  has  given  excellent  results,  though  I  have  not  sought  to  ohtain 
the  movable  joint  which  Mr.  Golding  Bird  hopes  may  follow  on  this 
method. 

The  transverse  incision  is  made  here  much  as  in  the  first  method, 
only  across  the  middle  of  the  patella ;  this  is  sawn  through  or  divided 
with  a  stout  knife,  the  fragments  turned  up  and  down,*  and  the  joint 
freely  opened  (Fig.  168).  To  facilitate  thorough  cleaning  out  of  the 
supra-pat ellar  pouch,  I  always  slit  this  up,  as  in  the  first  case,  by  a 
vertical  incision. 

C.  Semi-lunar  Flap  TMoreau,  Barker). — Here  a  large  U-shaped 
flap  is  raised  by  a  semi-lunar  incision,t  starting  above  one  condyle, 
descending  to  the  level  of  the  tibial  tubercle,  crossing  the  leg  here 
and  running  up  to  a  corresponding  point  on  the  other  side.  In  rais- 
ing this  flap,  which  includes  all  the  soft  parts  down  to  the  bone,  either 
the  ligamentum  patellie  should  be  severed  (suturing  of  this  being  re- 
sorted to  later),  or  the  tuberosity,  attached  to  the  ligament,  is  removed 
with  a  chisel,  and  subsequently  wired  down  (Barker). 

The  joint  being  opened  by  one  of  the  above  incisions,  the  surgeon 
begins  by  snipping  away,  with  blunt-pointed  scissors,  aided  by  mouse- 
tooth  forceps,  every  atom  of  pulpy  tissue  around  the  patella  and  liga- 
mentum i3atell8e,  going  as  close  to  the  bone  as  possible,  removing  com- 
pletely the  altered  ligamentum  mucosum  and  alaria.  Then  the  supra- 
patellar pouch  is  in  every  case  slit  up]};  with  a  sharp  bistoury  to  its  upper 
limits  (readily  reached  by  a  finger)  so  as  to  lay  bare  every  crevice  and 
remove  every  atom  of  altered  tissue.  The  vasti  fibres  will  now  be  bared, 
and  while  working  dow^nwards  on  the  inner  side  the  proximity  of  the 
femoral  vessels  must  be  remembered.  In  order  to  deal  as  systematically 
as  possible  with  the  diseased  synovial  tissue,  the  lateral  and  crucial 
ligaments  are  next  examined,  and  every  particle  of  diseased  tissue 
removed,  only  bright,  glistening,  clearly  healthy  ligamentous  tissue 
being  left.§  But  as  naked-eye  examination  in  parts  perhaps  not 
absolutely  bloodless  may  easily  be  fallacious,  it  is  much  better  in 
doubtful  cases  to  remove  these  comjjletely  than  to  run  any  risk  what- 
ever.    The  assistant  who  is  in  charge  of  the  limb  now  brings  the 

*  They  may  be  held  out  of  the  way  by  a  sharp  hook,  or  by  the  aseptic  fin<^er  of 
an  assistant. 

t  The  incision  should  begin  sufficiently  high  up  to  open  freely  the  supra-patellar 
pouch. 

X  I  look  on  this  as  one  of  the  most  cardinal  points  of  the  operation. 

§  Prof.  Oilier  {loc.  infra  cit.,  and  Rev.  de  Chir.,  1882)  drew  attention  to  preserving  the 
lateral  ligaments,  if  possible,  togetlier  with  all  healthy  periosteum  and  cupsule — i.e., 
those  tissues  which  will  keep  the  bones  in  place  and  which  will  tend  to  produce  ossify- 
ing material.  This  will  not  interfere,  if  carefully  carried  out,  with  extirpating  dis- 
eased parts,  while  it  will  go  far  to  prevent  progressive  flexion  of  the  joint. 


902 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


head  of  the  tibia  well  into  view  by  pulling  the  calf  of  the  leg  well 
forward  with  one  hand  while  he  further  dislocates  the  bone  by  push- 
ing up  the  leg  (Fig.  169). 


Fig.  169. 


The  condition  of  the  semilunar  cartilages  is  next  examined,  and  if 
they  are  much  invaded  by  pulpy  tissue,  or  if  it  is  intended  to  perform 
a  complete  excision,  they  must  be  cut  away  completely. 

The  back  of  the  joint  is  next  taken  in  hand.  This  region  can  be  far 
more  effectually  dealt  with  after  removal  of  the  ends  of  the  bones.  If, 
owing  to  the  case  being  an  early  one,  with  little  or  no  caries,  the  sur- 
geon  decides  to  remain  content  with  an  erasion,  he  must  still  deal 


EXCISION   OF  THE   KNEE.  903 

thoroughly  with  the  posterior  ligament*  and  deeper  parts  of  the  sides 
of  the  joint,  with  all  recesses  and  folds  of  the  synovial  membrane.  To 
expose  these  parts  thoroughly  is  a  matter  of  some  difficulty.  The 
assistant  should  manipulate  the  limb  as  above  directed  at  one  time, 
at  another  flex  the  leg  back  towards  the  table,  while  occasionally  a 
finger  in  the  popliteal  space  will  keep  within  reach  some  altered  tissue 
that  it  is  desired  to  deal  with.  Every  pains  must  be  taken  to  use  the 
scissors  systematically  and  thoroughly  here  as  elsewhere,'until  healthy 
tissues  are  reached,  and  not  to  dread  the  popliteal  artery  too  much. 
These  points  should  be  enforced  for  two  reasons.  If  any  diseased 
tissues  are  left  here  they  will  be  shut  in,  after  the  limb  is  extended, 
and  found  impossible  to  deal  with,  save  by  a  fresh  and  probably  un- 
successful operation.  Again,  there  is  always  a  risk,  especially  in  a 
surgeon's  earlier  operations,  of  his  not  dealing  with  disease  here  with 
sufficient  thoroughness  from  dread  of  injuring  the  popliteal  artery. 
This  vessel  may  be  avoided  by  (1)  not  dipping  the  points  of  the 
scissors  deeply,  but  using  the  blades  as  far  as  possible  parallel  with 
the  course  of  the  vessel;  (2)  by  remembering  that  even  after  the 
posterior  crucial  ligament  has  been  entirely  snipped  away  (a  matter 
often  imperfectly  done)  there  is  still  a  considerable  thickness  of  struct 
ures  in  front  of  the  artery.  (3)  In  a  case  where  it  is  necessary  to  go 
very  deeply  to  remove  all  doubtful  patches,  the  Esmarch  should  be 
slackened  and  the  pulsation  felt  for.     But  this  is  most  rarely  needed. 

After  all  the  diseased  tissues  at  the  back  have  been  thoroughly 
eradicated,  the  deeper  aspects  of  the  sides  of  the  joint  must  be  exam- 
ined. In  one  case  I  was  unable  to  satisfy  myself  that  the  limits  of  the 
diseased  tissues  were  reached  till  the  tendons  of  the  semi-tendinosus 
and  semi-membranosus  came  into  view ;  and  in  another,  that  of  the 
sartorius,  caseating  foci  having  spread  down  beneath  the  skin  on  the 
inner  side  of  the  joint.  If  an  erasion  is  thought  sufficient,  the  surgeon, 
having  gone  over  the  synovial  membrane  systf^matically  and  in  detail, 
now  attends  to  the  bones.  With  a  stout,  sharp  scalpel  he  scrapes  or 
pares  oflF  from  the  cartilaginous  surfaces  of  femur  and  tibia  any  adhe- 
rent pulpy  material,  removing  thin  shavings  of  the  cartilage  where 
needful.  This  must  be  carried  out  to  the  very  back  of  the  condyles 
and  throughout  the  inter-condyloid  notch,  and  around  the  posterior 
aspect  of  the  head  of  the  tibia,  if  diseased. 

It  now  remains  to  describe  the  removal  of  the  bones  in  case  erasion 
is  not  sufficient.  Thus,  excision  will  in  future  be  probably  called  for 
only  in  cases  of  long  standing,  where  caries  is  present,  and  in  those 
with  sinuses  and  suppuration.  Where  excision  is  evidently  needed, 
the  bones  should  be  sawn  after  the  supra-patellar  pouch  is  cleared 

*  This  and  the  posterior  parts  of  the  semilunar  fibro-cartilages  are  liable  to  be 
inefficiently  treated. 


904 


OPERATIONS   ON    THE    LOWER    EXTREMITY, 


out,  and  before  the  posterior  aspect  of  the  joint  is  taken  in  hand,  as 
this  step  will  be  much  facilitated  thereby. 

The  femur,  held  as  steady  as  possible,  is  taken  first.  A  groove  for 
the  saw  is  first  so  marked  out  with  the  scalpel  as  to  remove  about 
one-third  of  the  condyles.    In  severer  cases  or  where  the  above  section 


Fig.  170. 


Fig.  171. 


will  clearly  be  insufficient,  half,  or  even  two-thirds,  of  the  articular 
surface  may  be  removed,  but  no  section  should  be  made  further  back 
than  this,  or  the  epiphysis  will  be  trenched  upon  with  serious  after- 
results.*  The  section  of  the  femur  should  be  made  from  above  down- 
wards, and  slightly  from  behind  forwards  so  as  to  be  parallel  with  the 
articular  cartilage  and  at  right  angles  with  the  shaft. 

The  tibia  is  taken  next  and  a  groove  marked  out  with  the  knife 
about  2  inch  below  the  articular  cartilage.  A  Butcher's  saw,  set  hori- 
zontally, is  used  from  behind  forwards,  and  on  a  perfectly  level  plane. 
Neither  here  nor  in  sawing  the  femur  must  the  slightest  wobbling  of 
the  saw  be  permitted. 

About  i  inch  only  of  the  tibia  should  be  removed,  just  enough  in 

*  Dr.  Hoffa,  ofWiirzbnrg  {Arch.  f.  Klin.Ohir.,  Bd.  xxxii.  Heft  iv.  1885;  Annals  of 
Surgery,  March,  1886),  brings  forward  cases  to  show  that  removal  of  both  epiphyses 
led,  at  the  end  of  ten  years,  to  shortening,  amounting  to  25j  cm.  (1  cm.  =  -f^  inch), 
while  in  another  case  it  amounted  in  two  years  to  10  cm.  Loss  of  the  femoral  epi- 
physis alone  showed  17  cm.  of  shortening  in  six  years,  and  7  cm.  in  a  year  and  a  half. 
Two  cases  of  the  like  duration  affecting  tlie  tibial  line  showed  respectively  IS.y  and  6 
cm.  It  is,  however,  well  known  tliat  considerable  shortening  may  occur  in  cases  treated 
expectantly.  Dr.  Hoffli  found  in  one  case  that  at  the  end  of  twelve  years  the  shorten- 
ing amounted  to  18  cm.  with  ankylosis  at  an  angle;  in  nine  other  such  cases,  ranging 
in  duration  from  one  to  eiglit  years,  the  shortening  varied  from  1  to  13.}  cm.,  with 
angular  contraction  in  most  cases,  and  with  atrophy  and  tropliic  disturbances  very 
marked. 


EXCISION   OF    THE    KNEE.  905 

fact  to  expose  healthy  cancellous  tissue  and  no  more.  Of  the  femur, 
no  more  than  li  inches  should  be  removed  if  possible.*  Any  soft 
yellow,  cheesy,  fatty  patches,  any  cancellous  tissue  into  which  pulpy 
tissue  has  dipped  after  perforating  the  cartilage,  should  be  carefully 
removed  with  a  gouge.  Where,  however,  there  is  much  caries  or  the 
above  patches  are  numerous,  breaking  down  readily  under  the  finger- 
nail^ more  than  one  slice  of  bone  had  better  be  removed. 

Tlae  whole  wound  is  now  finally  most  carefully  scrutinized,  every 
outlying  angle  and  recess  being  examined  for  pulpy  tissue  left  behind. 

The  Esmarch's  bandage  is  now  removed,  and  while  lint  wrung  out 
of  1  in  20  carbolic  acid  is  held  firmly  over  the  sawn  tibia,  any  bleed- 
ing points  in  the  upper  half  of  the  wound  are  attended  to.  The  safest 
way  o|  ari'esting  the  bleeding  is  by  underrunning  with  chromic  gut 
and  fiiije  needles  all  the  vessels  which  spirt,  as  practiced  by  Mr.  Howse. 
Pressure  will  suffice  for  oozing.  Bleeding  from  the  cancellous  tissue 
will  be  arrested  by  placing  the  bones  in  contact.f 

The  pfttella,  if  sawn,  is  now  drilled  and  wired,  or  united  with  stout 
silk  or  (jhromic  gut.  I  prefer  the  first,  the  wire  being  left  long  and 
removed  in  about  a  fortnight. 

The  question  now  arises  whether  the  tibia  and  femur  should  be 
united  by  wiring  or  pegging. ;|:  I  am  of  opinion  that  if  the  bones  have 
been  so  saWn  as  to  bring  their  faces  squarely  together,  with  sufficiently 
exact  closaiess  to  prevent  more  than  a  finger-nail  being  inserted  be- 
tween theni,  and  if  they  are  put  up  with  the  security  which  is  given 
by  Mr.  Ho^'se's  method,  the  above  aids  are  not  needed. §  Failure  of 
excision  is  due  not  to  deficiency  of  repair  in  the  bones,  but,  as  a  rule, 
to  persistency  of  pulpy,  tubercular  material. 

Mr.  Barker  (Hunt.  Lect.,  supra  cit.)  does  not  remove  the  Esmarch 

*  Very  much  larger  amounts  may  be  removed  if  needful,  especially  in  children  and 
young  adults,  with  good  reparative  power.  If  the  surgeon  is  obliged  to  trench  upon 
the  epiphysis  it  should  be  with  the  gouge,  and  not  with  tlie  saw,  if  possible.  In  one 
case  of  a  boy,  aged  seven,  the  bones  being  carious,  soft,  and  fatty,  a  large  patch  of 
cheesy,  fatty  bone  presented  itself  in  the  head  of  tiie  tibia  after  the  first  slice  had  been 
removed.  On  removing  this,  the  gouge  entered  the  medullary  canal,  which  was  ex- 
posed, gaping  on  the  sawn  surface.  I  was  doubtful  how  far  union  would  take  place 
here,  but  three  years  later  the  boy  had  a  most  useful  limb,  probably  from  a  ring  of 
epiphysial  tissue  being  left. 

t  The  following  vessels  will  be  found  to  give  the  chief  trouble  after  a  combined 
erasion  and  excision :  One  or  two  running  down  in  the  periosteum  over  the  femur, 
one  or  two  in  the  cut  periosteum  surrounding  the  sawn  margin  of  the  tibia,  and  one 
from  the  azygos-articidar  in  the  posterior  ligament. 

X  The  bones  have  been  united  with  different  forms  of  pegs  or  nails,  or  by  wire,  stout 
carbolized  silk,  or  chromic  gut. 

§  I  may  be  speaking  with  insufficient  knowledge,  but  I  am  under  a  strong  impression 
that  the  advocates  of  these  aids  have  not  made  trial  of  the  absolute  fixity  ensured  by  a 
well-applied  Howse's  splint  {vide  infra'). 


906  OPERATIONS   ON   THE    LOWER    EXTREMITY. 

till  the  wound  is  dressed  and  bandaged.  Any  vessels  that  can  be  seen 
are  secured  before  the  wound  is  closed,  but  the  chief  means  of  meet- 
ing bleeding  are  by  firm,  even  bandaging  over  antiseptic  dressings, 
and  by  keeping  the  limb  in  an  almost  perpendicular  position  for  the 
first  few  days.  It  is  not  stated  how  this  is  done,  nor  whether  this 
position  is  followed  by  troublesome  oozing. reaching  to  the  end  of  the 
splint.  Having  seen  in  one  case  almost  fatal  hsemorrhage  follow  on 
excision  of  the  knee  put  up  carefully  in  the  box  splint  of  seventeen 
years  ago — the  blood  running  through  the  bed  on  to  the  floor — I  much 
prefer  to  follow  Mr.  Howse's  method  of  underrunning  the  chief 
bleeding-points. 

The  amount  of  drainage  needed  will  vary.  I  usually,  even  in  the 
least  severe  cases,  insert  one  drainage-tube  projecting  above  from  the 
remains  of  the  supra- patellar  i)ouch,  and  below  (by  a  counter-puncture) 
low  down  on  the  outer  aspect  of  the  popliteal  space.  Where  t-iere  has 
been  much  pulpy  mischief  to  clear  out,  or  much  oozing,  the  above 
should  never  be  dispensed  with,  and  another  tube  should  be  similarly 
placed  on  the  inner  side.  Two  or  three  sutures  may  be  made  use  of 
in  the  middle  of  the  incision,  the  sides  being  always  left  open.  Before 
closing  the  wound  I  dust  a  little  iodoform,  finely  powdered,  over  the 
different  surfaces,  and  dry  these  scrupulously,  when  the  sutures  are 
in  place.  Mr.  Howse's  splint  is  now  applied.  To  those  who  are  not 
familiar  with  the  most  excellent  method  devised  by  my  colleague,  the 
following  brief  account*  may  not  be  unwelcome.  The  arrangement 
will  be  found  most  simple,  and  equally  efficient  in  admitting  of  anti- 
septic dressing  and  maintaining  the  parts  in  absolute  rest.  The  splint 
consists  of  two  interrupted  tinned-iron  troughs  for  the  thigh  and  leg 
joined  by  a  posterior  bar.  This  is  from  4  to  6  inches  long,  according 
to  the  age  of  the  patient;  it  is  convex  from  side  to  side  to  avoid  cut- 
ting into  the  popliteal  space,  and  can  be  lengthened  cr  shortened  if 
any  alterations  in  the  interruption  are  required.  At  the  end  of  the 
splint  is  an  adjustable  foot  piece. 

The  limb  being  laid  in  the  splint,  attention  must  be  paid  to  the 
posterior  bar  being  in  the  centre  of  the  popliteal  space,  the  foot  must 
be  well  down  on  the  foot-piece ;  if  the  splint  grips  the  thigh  or  leg 
too  tightly  or  rides  too  loosely,  it  must  be  bent  out  or  in  with  iron 
"  crows."  The  dressings  are  now  applied,  preferable,  I  think,  those 
of  dry  sal  alembroth  or  iodoform  gauze.  Great  care  must  be  taken 
to  bandaging  from  below  upwards  and  from  within  outwards,  the 
bandage  being  laid  on  evenly  and  firmly  so  as  to  distribute  the  dis- 
charges, evenly,  right  through  the  dressings,  and  to  prevent  their 
coming  through  at  one  or  two  spots.     The  splint  is  next  secured  to 

*  Ouy's  Hosp.  Reports,  1877,  vol.  xxii.  p.  503,  and  the  accompanying  plate. 


EXCISION    OF   THE    KNEE.  907 

the  limb  with  "  waxed  bandages,"  prepared  by  passing  them  through 
a  mixture  of  ordinary  yellow  wax  and  olive  oil,  in  proportions  suffi- 
cient to  make  the  wax  soft  and  workable.  After  they  are  applied 
to  the  leg  and  thigh  they  are  painted  over  with  a  little  hot  wax 
mixture,  so  as  to  make  them  weld  into  one  mass.*  The  limb,  thus 
secured,  is  slung  with  cord  and  pulley  to  a  Howse's  cradle.  This 
occupies  the  lower  part  of  the  bed',  the  patient  lies  on  a  half 
water-bed. 

The  chief  points  here  are  (1)  to  ensure  as  absolute  immobility  as 
possible;  (2)  to  employ  as  infrequentf  dressings  as  practicable;  (3) 
to  watch  for  every  sign  of  relapse,  and  to  attack  it  as  soon  as  noticed. J 

After-treatment. — Morphia  or  laudanum  should  be  used  freely 
at  first,  if  needful.  If  the  temperature  keep  down,  the  dressings 
should  be  left  undisturbed  for  two  weeks,  when  an  anaesthetic  should 
be  given  to  remove  the  wire  if  the  excision  has  been  a  trans-patellar 
one,  take  out  any  drainage  tubes,  and  also  to  make  -sure  that  there 
are  no  persistent  sinuses  pointing  to  residual  pulpy  material.     These, 

*  The  splint  is  usually  lined  with  lint  wrung  out  of  the  above  mixture.  But  the 
popliteal  bar  and  any  of  the  splint  close  to  the  wound  must  be  metal  only,  uncovered, 
to  favor  asepsis.  If  any  spaces  are  found  to  exist  between  the  limb  and  the  splint  they 
may  be  filled  in  with  cotton-wool,  soaked  in  some  of  the  hot  wax  mixture. 

t  Infrequency  of  dressings  has  been  strongly  insisted  on  by  Prof.  Oilier  {Bev.  de 
Chir.,  August,  1887 ;  Annals  of  Surgery.  November,  1887,  p.  424).  This  most  important 
economy — of  pain  to  the  patient,  and  time  to  the  surgeon — is  only  to  be  secured  by — 
(1)  Removing  every  atom  of  the  disease  that  can  be  got  at  '(2)  Providing  drainage. 
The  more  thoroughly  the  disease  is  extirpated,  th«  less  need  is  there  to  drain;  but 
however  completely  the  disease  is  removed,  many  sutures  should  not  be  employed, 
especially  at  the  ends  of  the  wound.  (3)  Usingdrydressings.  Of  these  sal  alembroth 
or  iodoform  gauze  (either  being  used  with  iodoform)  is  the  best,  the  first  being  the  one 
I  prefer,  from  its  efficiency,  its  softness,  its  cheapness,  and  the  fact  that  the  parts  not 
discolored  by  the  discharges  can  be  used  again.  Excellent  pion«ering  work  as  car- 
bolic oil  gauzedid,it  had  the  greatdisadvantageof  being  moist.  Unless  most  carefully 
wrung  out — a  thing  difficult  to  secure  in  a  surgical  ward,  where  a  large  number  of 
dressings  have  to  be  provided  together — within  twenty-four  hours,  it  was  difficult  to 
say  how  much  of  the  discharge  was  oily  and  how  much  serous;  the  surgeon  knowing 
that  he  should  not  have  a  chance  of  seeing  the  case — perhaps  an  important  one — for 
another  twenty-four  hours,  had  the  dressings  changed,  very  often,  I  think,  needlessly. 
Of  course,  in  many  cases  this  infrequency  of  dressings  is  impossible  to  secure — e.gr., 
where  all  the  disease  cannot  have  been  removed  at  the  first  operation,  and  the  tem- 
perature keeps  up,  probably  accompanied  with  pain ;  (2)  where  sinuses  have  been 
present,  and  the  joint  is  probably  septic.  In  such  cases,  if  needful,  the  dressings  must 
be  changed  daily,  to  enable  the  surgeon  at  onee  to  decide  as  to  the  need  of  again 
attacking  any  relapse  (vide  infra).  Infrequency  of  dressings  will  not  interfere  with 
the  use  of  drainage-tubes. 

X  It  is  especially,  I  think,  to  neglect  of  this  last  detail,  that  the  fact  arises  that 
almost  as  many  cases  are  lost  from  mistakes  in  the  after-treatment  as  from  want  of 
skill  in  the  operation. 


908  OPERATIONS    ON   THE    LOWER    EXTREMITY. 

if  found,  must  be  slit  up  with  a  sharp-pointed  curved  bistoury,  and 
scraped  out  with  a  sharp  spoon.  Wliile  this  may  be  repeated  every 
ten  days,  on  five  or  six  occasions  successfully,  the  more  deliberately 
the  surgeon  endeavors  to  extirpate  the  disease,  both  in  the  soft  parts 
and  in  the  bones,  the  more  be  treats  it  as  if  malignant  at  first,  the 
less  often  will  he  have  to  interfere  with  the  rest  of  the  parts  after- 
wards. 

In  about  three  months  INIr.  Howse's  splint  may  be  left  off  and  a 
leather  splint  fitted  on^  carrying  a  metal  bar  to  resist  the  tendenc}''  to 
flexion.  Some  such  fixed  apparatus  should  be  worn,  in  children,  for 
three  or  more  years.* 

Causes  of  Failure  and  Death  after  Excision  of  the  Knee. 

1.  Inveterate  ]>orsistonee  of  pulj)y  material  leading  to  («)  giving  way 
of  the  supra-patellar  pouch,  and  the  results  mentioned  at  p.  900;  (/?) 
to  formation  of  caseating  foci,  especially  at  the  back  of  the  joint 
(p.  902),  and  only  to  be  removed  by  re-excision  or  amputation. 

2.  An  unhealthy  condition  of  the  bone-ends,  with  caries  and  chronic 
osteo-myelitis. 

3.  Deficient  reparative  power,  leading  to  bed  sores,  emaciation,  irri- 
tative fever,  hectic. 

4.  Coexistence  or  subsequent  development  of  such  visceral  diseases 
as  phthisis,  etc. 

5.  Surgical  scarlet  fever. 

6.  Septic  Conditions. — For  these  the  surgeon  will,  nowadays,  be,  as 
a  rule,  entirely  to  blame. 

7.  Tetanus  (p.  897). 

8.  Secondary  Haemorrhage. — Another  very  rare  condition  (p.  906). 

9.  Fat  Embolism. — This  is  a  still  rarer  condition,  but  one  which,  on 
account  of  the  interest  it  excited  some  years  ago,  and  because  it  has 
once,  at  least,  proved  fatal,  deserves  mention  here.  The  case  was  that 
of  a  child,  aged  twelve,  submitted  to  excision  for  puli>y  disease  by 
Vogt,  of  Griefs wald.f  The  bones  were  so  fatty  as  to  cut  with  a  knife. 
Though  but  little  chloroform  had  been  given,  and  the  loss  of  blood 

*  In  early  life  callus-Hke  material  i&  thrown  out  quickly,  and  often  somewhat  irreg- 
ularly, between  the  bones,  but  it  is  extremely  slow  in  really  ossifying.  As  the 
quadriceps  extensor  wastes  much  more  quickly  than  the  hamstrings,  even  when  the 
patella  is  retained,  the  latter  muscles  keep  up  their  action  on  the  tibia  for  months,  and 
even  for  j'ears,  until  the  onion  is  firm.  Tenotomy  has  been  advised,  and  even  resection 
of  all  (he  hamstring  tendons  (Dr.  Phelps,  NewYark  Med.  Record,  July  21, 1886  :  Annals 
of  Surgery^  October,  1886,  p.  364).  I  think,  however,  that  retaining  the  bones  immo- 
bile and  in  good  position,  securing  early  h^-aling  of  the  wound,  wearing  a  stiff  appa- 
ratus, and,  wherever  practicable,  using  the  trans-patellar  method,  will  best  ensure  a 
limb  soundly  ankylosed  in  good  position.. 

t  Cent./.  C'kir.,  18S3,  p.  24. 


EXCISION    OF   THE    KNEE.  909 

had  been  slight,  the  patient  died  twenty-four  hours  later  with  shallow 
respirations,  feeble  pulse,  and  low  temperature.  Fat  embolism  of  the 
lungs,  extensively  diffused,  was  found  post  mortem, 

Vogt  considered  that  this  case  predisposed  to  fat-embolism.  Thus 
cut  vessels  were  exposed  on  the  sawn  surfaces  with  plenty  of  free  oily 
matter  close  by,  and  unable  to  escape,  owing  to  the  bone-ends  being 
in  close  contact  (two  wire  sutures  Avere  used).  A  similar  case,  after 
resection  of  the  hip,  by  Prof.  Liicke,  is  mentioned.  Prof.  Vogt  thought 
that  he  would  amputate  in  another  case  if,  after  excision  of  the  knee, 
the  limb  could  not  be  straightened  without  close  apposition  of  the 
sawn  fatty  bone- ends. 

10.  Shock. — This,  though  very  rare,  must  be  borne  in  mind.  Eleven 
years  ago  I  lost  a  case  from  this  cause.  The  patient  was  a  delicate 
boy,  aged  seven,  with  a  large  pulpy  knee.  As  there  was  no  suppura- 
tion, no  sinuses,  nor  evidence  of  much  mischief  in  the  bones,  I,  unwisely 
as  it  proved,  tried  to  save  the  limb.  The  child  sank  a  few  hours  after- 
wards. Volkmann  (Centr.f.  Chlr.,  Bd.  xii.  Heft  9,  Feb.  28,  1885;  Ann. 
of  Surg.,  May,  1S85,  p.  486)  draws  attention  to  the  need  of  taking  care 
in  children  that  too  much  blood  is  not  lost,  and  that  deep  narcosis  is 
not  too  prolonged. 

Erasion  of  the  Knee  compared  with  Excision. — I  must 
confess  to  looking  upon  erasion  alone  with  much  suspicion.  Excision 
combined  with  erasion  gives  such  good  results  that  I  have  been  dis- 
inclined to  substitute  any  operation  for  it,  and  thus  have  only  per- 
formed erasion  alone  on  two  occasions ;  one  of  these  was  most  entirely 
successful,  the  other  required  excision,  and  the  child  did  well  after- 
wards. 

The  advantages  claimed  for  erasion  over  excision  are  mainl}'  two. 
(1)  That  there  is  no  removal  of  bone  and,  still  less,  any  risk  of  inter- 
ference with  the  epiphyses.     (2)  That  the  joint  may  retain  mobility. 

(1)  This  is  certainly  correct.  In  one  of  my  cases  the  child  not  only 
had  no  shortening,  but  repeated  careful  measurements  showed  that 
the  limb  on  which  erasion  of  the  knee  had  been  performed  was  actu- 
ally f  inch  longer  than  its  fellow.  But  though  absence  of  shortening 
may  be  often  secured,  I  think  that  this,  like  other  advantages,  maybe 
secured  at  too  great  a  risk.  Erasion  alone  will  need  to  be  done  with 
exceeding  care  if  pulpy  disease  is  not  to  be  left  behind.  It  may  be 
asked  how  removal  of  the  bone-ends  facilitates  removal  of  the  pulpy 
material,  if  care  has  been  taken  to  open  the  joint  thoroughly  in  the 
course  of  the  erasion.  I  would  reply  that  it  does  so  in  two  ways,  and 
in  two  very  cardinal  places.  Firstly,  the  removal  of  n  slice  of  the  femur 
makes  it  very  much  easier  to  get  at  the  posterior  crucial  and  the  pos- 
terior ligaments,  and  any  pulpy  tissue  in  the  intercondyloid  notch. 
In  tlie  second  place,  after  removing  the  articular  surface  of  the  tibia. 


910  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

the  condition  of  the  posterior  part  of  the  semilunar  cartilages  can  be 
much  more  thoroughly  investigated. 

(2)  Witli  regard  to  the  retention  of  mobility  I  have  not  the  shadow 
of  a  doubt  that  a  large  number  of  erasions  will  show  that  movement 
is  often  accompanied  by  a  degree  of  permanent  flexion.  I  should 
strongly  dissuade  from  any  attemj^t  to  secure  mobility  in  the  case  of 
the  knee  and  ankle. 

I  trust  that  the  account  of  the  operation  of  combined  erasion  and 
excision  will  be  found  to  contain  suflficient  information  to  help  those 
who  wish  to  make  trial  of  erasiorv  only.  Those  interested  in  the  sub- 
ject should  refer  to  the  papers  in  which  my  old  friend  G.  A.  Wright, 
of  Manchester,  brought  this  subject  before  the  profession.*  Two  points 
require  a  word  from  me.  It  will  be  seen  that  he  advises  that  the  cru- 
cial ligaments  be  scraped  but  carefully  preserved.  I  doubt  the  wisdom 
of  this  in  any  case,  especially  those  where  erasion  has  been  attempted 
in  cases  of  pulpy  disease  at  all  advanced.  The  other  is  the  statement 
that  erasion,.  if  it  fails,  leaves  the  limb,  little,  if  at  all,  in  worse  condi- 
tion for  excision  afterwards.  This  may  be  misleading  if  not  carefully 
read.  It  is  true  of  the  limb  but  not  of  the  joint.  In  the  case  of  mine 
which  required  excision,  I  found  that  the  previous  erasion  had  entirely 
obliterated  the  usual  landmarks,  and  that  much  difficulty  was  experi- 
enced and  much  care  needed  in  dealing  with  such  parts  as  the  remains 
of  the  posterior  ligament. 

*  Lancet,  1881,  vol.  ii.  p.  992;  Med.  Chron^.lwU,  IBfio.  See  also  a  paper  by  Mr. 
Shield  {Ann.  of  Sur<j  ,  Feb.,  1888).  The  following  are  Mr.  Wright's  conclusions:  "  In 
those  that  have  done  well  the  common  fiictors  appear  to  be  :  (1)  absence  or  very  small 
amount  of  suppuration  ;  (2)  superficial  or^  at  least,  not  widespread  bone  disease;  (3) 
absence  of  general  tuberculosis.  In  short,  fairly  early  disease  in  a  not  hopelessly 
tuberculous  child.  This  pretty  well  corresponds  to  the  cases  generally  considered 
suitable  for  excision.  I  have  not  yet  tried  the  operation  in  adults.  It  is  clear  that 
extensive  disease  of  bone  and  much  suppuration  will  not  allow  good  results  to  be  ob- 
tained by  erasion  ;  neither,  as  a  general  rule,  will  they  by  excision,  though  I  am  quite 
sure  that  the  knee  may  be  succt>ssfully  excised  in  cases  wiiere  erasion  is  out  of  the 
question,  as  shown  by  excision  succeeding  where  erasion  has  failed.  Although  in  one 
case  a  freely  movable  joint  resulted,  I  do  not  advise  the  attempt  to  obtain  mobility  by 
early  passive  movement,  except  in  a  few  instances  where  the  wound  has  healed  at  once, 
and  there  is  no  obstacle  in  the  way  such  as  dense  and  lowly  vitalized  cicatricial  tissue. 
Erasion,  if  it  fails,  leaves  the  limb  little,  if  at  all,  in  worse  condition  for  excision 
afterwards.  In  those  cases  where  amputation  became  necessary,  either  the  local  or 
constitutional  condition  forbade  hope  of  successful  excision  Where  it  succeeds,  erasion 
leaves  as  sound  a  limb  as  excision,  without  shoriening.  In  some  cases  there  may  be 
rao))ility,  though  1  think  in  most  it  will  be  found  that  there  is  not  enough  mobility  to 
be  useful;  here  the  limb  is  very  liable  to  become  flexed  after  healing  of  the  wound, 
but  the  same  is  true  of  excision  in  children.  I  think,  then,  that  in  suitable  cases  era- 
sion is.  in  disease  of  the  knee,  better  surgery  than  excision,  but  its  application  is 
strictly  limited.     In  all  cases  I  have  employed  strictly  Listerian  antiseptics.'' 


WIRING   FRACTURES   OF   PATELLA.  911 


WIRING  UNUNITED  FRACTURES  OF  PATELLA.* 

This  operation,  brought  before  the  profession  by  Sir  J.  Lister  in 
1883,  seems  lately  to  haA'^e  dropped  out  of  notice.  This  is  perhaps  due 
to  two  facts :  (a)  In  the  majority  of  cases  a  quite  sufficiently  good 
result  is  obtained  by  non-operative  means.  (6)  In  spite  of  the  vastly 
increased  familiarity  with  antiseptic  details,  and  their  simplification, 
much  of  the  old  dread  of  opening  the  knee-joint  still  survives.  The 
question  was,  however,  sufficiently  thnished  out  to  make  it  clear  that 
the  operation  is  justifiable  under  certain  conditions.  The  indications 
may  be  stated  somewhat  thus  : 

1.  In  Sir  J.  Lister's  words  (loc.  suj)ra  cit.),  "no  man  is  justified  in 
performing  such  an  operation  unless  he  can  say  with  a  clear  conscience 
that  he  considers  himself  morally  certain  of  avoiding  the  entrance  of 
any  septic  mischief  into  the  wound." 

2.  Certain  Cases  of  Old  Fracture  of  the  Patella. — This  important 
matter  must  be  taken  somewhat  in  detail.  The  chief  points  here  jus- 
tifying resort  to  wiring  are — (a)  Failure  of  previous  treatment,  espe- 
cially is  hospital  patients,  (b)  A  useless  limb,  especially  in  a  man 
whose  occupation  entails  much  walking  or  standing,  where  the  gait 
is  helpless  and  requires  much  attention,  or  where  many  falls  have  fol- 
lowed involving  serious  risk  of  fracture  on  the  opposite  side,  (c) 
Where  both  patellar  are  fractured,  {d)  Where  the  patient  is  young 
and  has  many  years  of  active  life  before  him.  (e)  Where,  if  not  young, 
the  patient  is  sufficiently  healthy.  (/)  Where  enough  is  known  of 
the  patient's  habits  to  ensure  his  being  amenable. 

3.  Recent  Fractures. — These  must  be  considered  separately,  accord- 
ing as  they  are — (a)  simple;  or  (6)  compound.   In  the  former  case  the 

.general  opinion  of  the  profession  has  appeared  to  be  against  operation, 
owing  to  the  good  result  which  usually  follows  on  non-operative 
measures.  Prof.  Lister'sf  five  cases  of  wiring  in  recent  fractures  prove 
how  safe  this  method  is  in  skilled  hands,  (b)  In  compound  fractures 
the  matter  seems  to  be  different.  Here  a  wound  already  exists,  and  if 
the  patient's  condition  is  good  no  harm  can  be  done  by  wiring,  w^ith 

*  Mr.  Ogier  Ward  {Lancet,  November  1,  1884),  in  some  interesting  remarks  on  three 
cases  -of  wliicli  one  was  treated  without,  and  the  other  two  by,  wiring — shows  that  in 
the  first  the  total  time  List  before  resuming  work  was  twenty-seven  weeks,  and  in  the 
two  wired,  tliirteen  and  eight  weeks  respectively;  that  the  first  case  cf>nld  not  kneel 
before  nine  months,  while  the  other  two  could  do  so  six  and  five  weeks  after  the  oper- 
ation.    It  will  be  seen  that  the  loss  of  time  was  reduced  by  more  than  one-half. 

t  Sir  .Joseph  goes  so  fiir  as  to  consider  {Lancet,  November  3,  1883)  that  "the  unu- 
nited case  is  in  every  respect  worse  as  a  sulyect  of  operation  than  the  recent."  Tliis  is 
chiefly  owing  to  the  wasting  of  fragments  and  their  greater  separation.  Again,  in 
recent  cases,  there  is  no  need  to  pare  the  fragments,  for  after  sponging  away  of  clots 
the  surfaces  are  ready  for  coaptation. 


912  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

antiseptic  precautions,  any  fragments  which  appear  to  be  widely  sep- 
arated. Furthermore,  such  a  step  may  be  easily  combined  with  the 
needful  examination  and  irrigation  of  the  joint  with  dilute  solution  of 
mercury  perchloride  or  carbolic  acid,  and  the  insufflation  of  iodoform* 
Operation. — The  parts  being  thoroughly  cleansed,  an  incision  is 
made,  with  the  strictest  antiseptic  precautions,  including  the  spray, 
about  3]  inches  long,  either  verticall}^  or  transversely.  The  former  is 
adopted  by  Sir  J.  Lister.  The  latter  is  the  more  convenient,  and 
admits  more  readily  of  getting  at  the  lateral  aspectsof  the  joint,  if  the 
aponeurosis  above  requires  division  at  these  points. f  It  is  said  to  have 
the  disadvantage  of  being  more  likely  to  give  way  and  expose  the  joint 
if  a  refracture  should  take  place  later.  I  used  it  in  the  two  cases  men- 
tioned below,  and  think  it  well  to  make  it  rather  above  or  below  the 
interval  between  the  fragments,  so  that  this  and  the  wound  shall  not 
lie  opposite  to  each  other.J  The  fragments  when  exposed§  are  generally 
found  embedded  in  fibrous  tissue,  thickened  synovial  membrane, 
and  old  decolorized  coagulum.  This  must  be  snipped  or  cut  away, 
and  any  spirting  vessels  in  the  thickened  synovial  membrane  must  be 
secured.  A  very  thin  section  from  each  fragment  is  then  removed  with 
a  narrow-bladed  saw,  this  needing  much  caution  in  the  case  of  the 
lower  one,  which  is  the  smaller  of  the  two.  If  the  fragments  can  now 
be  pressed  into  close  apposition,  nothing  remains  save  to  wire  them, 
but  the  case  is  by  no  means  so  simple  where  the  bones  are  widely 
apart.  Thus,  in  one  of  my  cases,  after  paring  the  fragments,  these 
were  quite  2't  inches  from  each  other,  and  after  most  forcible  traction, 
the  upper  could  only  be  made  to  descend  f  inch.  Malgaigne's  hooks 
were  now  applied  and  tightly  screwed  up,  but  with  no  result  on  the 
desired  approximation.  The  lateral  expansions  of  the  quadriceps 
were  next  still  more  fully  divided  (cut  muscular  fibres  being  seen  on 
the  inner  side),  but  the  fragments  were  almost  as  far  apart  as  ever. 
As  the  only  alternative  to  excising  the  joint  (in  order  to  substitute  a 
firm  support  for  the  flail-like  limb),  I  now  divided  partially  the  rectus 
tendon,  but  it  was  not  till   the  upper  fragment  was  only  held  by  a 


*  Dr.  G.  K.  Fowler,  of  New  York  (Annals  of  Surgery,  September,  1885,  p.  248), 
calls  attention  to  the  <>;reat  importance  of  making  these  cases  aseptic  at  tlie  first.  In  his 
case  the  bone  was  split  into  three  fragments.  Tlie  two  lower  ones  were  first  wired 
together,  and  their  upper  margins  were  next  siitnred  to  the  upper  fragment  by  two 
sutures,  one  for  each  lower  fragment. 

t  It  would  also  be  probably  more  convenient  in  a  compound  fracture. 

J  An  Esmarch's  bandage  is  not  needed,  and  would  have  the  objections  of  causing 
oozing  afterwards  into  the  joint  cavity,  and  also  of  preventing  that  bringing  down  of  the 
extensors  of  the  thigh  whicli  may  be  required  in  cases  of  wide  .separation. 

§  In  one  case,  the  skin  being  dimpled,  puckered  down,  and  adherent  between  the  frag- 
ments, I  had  to  cut  away  a  piece  about  |  inch  in  diameter. 


WIRING    FRACTURES    OF    PATELLA.  913 

narrow  stout  band  at  its  upper  and  inner  parts  that  it  could  be 
brought  in  apposition  with  the  lower  one.   •The  result  was  excellent- 

In  these  difficult  cases  it  must  be  remembered  that  it  is  not  abso- 
lutely necessary  to  get  the  fragments  into  exact  apposition.  If  after 
wiring  they  come  within  i  inch  of  each  other,  the  limb  will  be  a  most 
useful  one,  though  of  course  exact  apposition  is  to  be  desired.*  When, 
in  spite  of  all  the  above,  approximation  of  the  fragments  is  still  im- 
possible— though  it  is  difficult  to  imagine  such  a  contingency — the 
knee  should  be  excised  either  now,  or  on  another  occasion,  so  as  to 
give  a  firm  support. 

The  fragments  being  sufficiently  approximated,  they  are  now  drilled. 
This  may  be  easily  effected  by  an  oi-dinary  clean  bradawl.  The  bones 
should  be  drilled  obliquely,  the  instrument  entering  each  fragment  a 
full  2  inch  from  the  fracture  on  the  upper  surface,  and  emerging  above 
the  cartilaginous  surface  below.f  Where  the  lower  fragment  is  too 
small  to  hold  a  wire,:{:  this  may  be  passed  through  the  ligamentum 
patellae,  as  has  been  done  by  Sir  J.  Lister  (foe.  supra  cit.)  and  Mr, 
Teale.§  One  wire  would  appear  to  be  sufficient :  though  this  unites 
the  centre  of  the  fragments  exactly,  a  very  slight  interval  remains  at 
the  edges,  but  does  not  interfere  with  an  excellent  result. 

When  the  wire  is  twisted,  two  half  twists,  or  one  comj)lete  one,  will 
be  sufficient,  and  it  should  be  noted  at  the  time  in  which  direction 
the  twist  is  made,  in  case  the  wire  is  removed.  This  raises  the  ques- 
tion as  to  the  best  way  of  dealing-  with  the  wire,  whether  to  cut 
it  short  and  embed  the  ends  by  gently  hammering  them  into  the 
fibrous  tissue  over  the  upper  fragment,  or  to   leave   the  wire  long 

*  In  a  case  of  Mr.  Wheelhouse's  (/?n<.  3fed.  Journ.,  June  9,  1883)  the  fragments, 
originally  li  inch  apart,  could  only  be  brought  witliin  4  inch  of  each  other;  an  excellent 
limb  resulted. 

t  While  it  is  well  to  take  this  last  precaution,  it  probably  does  not  matter  much 
(supposing,  of  course,  that  strict  antiseptic  precautions  are  taken)  if  the  wire  is  passed 
within  the  joint.  Sir  J.  Lister  gives  the  following  aid  to  making  the  two  drill-holes 
exactly  correspond  :  "Supposing  that  on  one  side  the  instrument  should  have  come 
too  far  down,  it  may  be  into  the  cartilage ;  we  do  not  regard  that  at  first,  but  pass  the 
wire  through  the  two  drill-holes,  and  then  on  that  side  on  which  tlie  hole  has  come 
too  far  down,  by  means  of  the  bradawl  we  simjdy  chip  away  a  little  of  the  material 
that  is  above  the  wire,  until  the  wire  comes  to  be  in  a  position  exactly  opposite  to 
the  hole  on  the  other  side."  If,  in  another  case,  there  is  difSciilty  in  making  the 
drill  emerge  upon  the  fractured  surface,  Sir  Joseph  would  advise  to  withdraw  the  drill 
and  substitute  the  blunt  end  of  a  needle,  and  then  with  a  gouge  or  bradawl  to  excavate 
an  opening  upon  the  fractured  surface,  opposite  to  the  other  drill-hole,  until  the  needle 
is  exposed  ;  the  wire  can  then  be  easily  passed. 

X  The  most  difficult  fragment  should  be  taken  first.  The  wire  is  liable  to  hitch  at 
two  points— one  in  liitling  off  the  drilled  orifice  in  the  second  fragment;  the  other,  as 
it  comes  up  through  the  fibrous  tissue  covering  this  fragment. 

§  Brit.  Med.  Journ.,  June  9,  1883. 

58 


914  OPERATIONS    ON    THE   LOAVER    EXTREMITY. 

enough  to  admit  of  its  being  removed  later.  I  have  alluded  to  this 
question  at  p.  78.  Sir  J.  Lister  advocates  the  former  course.  I  shall 
not,  I  trust,  be  thought  wanting  in  proper  respect  if  I  suggest  that  in 
the  knee,  at  least  in  women  who  have  much  kneeling,  removal  of  the 
wire  will  be  more  satisfactory.  Thus,  in  one  of  my  cases,  in  which  I 
had  hammered  down  the  wire,  the  woman  returned  nearly  a  year 
later  to  have  the  wire  removed.  She  had  not  been  able  to  kneel,  the 
suture  could  be  felt,  and  at  one  spot  the  skin  was  ulcerating  over  it. 
I  ought  to  state  that  the  patient  was  a  very  thin  one,  and  that  I  had 
made  three  or  four  half  turns  instead  of  two  (p.  903).* 

Before  the  wire  is  twisted  or  hammered  down,  if  this  course  is 
decided  upon,  the  surgeon  must  decide  as  to  drainage  of  the  joint. 
When  the  operation  has  been  difficult,  involving  much  separation 
of  adhesions,  and  interference  with  the  parts,  drainage  should  be 
employed  either  by  inserting  a  tube  or  horsehair  drain  into  each 
angle  of  the  wound  if  a  transverse  one  has  been  made,  or,  more  effici- 
ently, by  passing  a  narrow-bladed  dressing-forceps  through  the  wound 
to  the  most  dependent  part  of  the  joint  at  the  outer  side  (Lister), 
thrusting  the  instrument  here  through  the  joint  and  soft  parts,  cutting 
upon  it  and  drawing  a  drain  through.f  The  wound  is  then  united 
and  dressed.  As  soon  as  the  deeper  part  of  the  wound  is  healed, 
every  pains  must  be  taken,  by  massage,  etc.,  to  improve  the  atrophy 
of  the  quadriceps.  Healing  should  be  complete  in  three  weeks.  If 
it  be  decided  to  remove  the  wire,  this  may  be  done  six  or  eight  weeks 
after  the  operation,  by  making  a  small  incision  through  the  scar. 
The  number  of  half-twists  and  the  direction  in  which  they  have  been 
made  must  be  recollected  at  this  time.  The  wire  is  first  untwisted 
and  straightened,  one  end  is  next  cut  off  short,  and  the  other  grasped 
in  dressing-forceps,  and  wound  round  the  tips  of  these.  It  is  then 
extracted  without  jerking. 

The  question  of  passive  movement  now  arises.  Usually,  about 
six  or  eight  weeks  after  the  operation,  the  patient  may  get  up  and 
begin  to  use  the  limb  (with  the  aid  of  two  sticks  at  first),  flexion  and 
extension  being  diligently  practiced.  Unless  the  joint  is  very  stiff, 
massage,  friction,  and  gentle  persevering  movement,  aided  by  time 

*  Dr.  Macewen  {loc.  infra  eit.)  mentions  a  case  wliich  came  under  observation  three 
months  after  suture  of  llie  patella,  with  acute  suppurative  arthritis  of  the  joint  and 
ulceration  of  the  cartilage.  A  probe  passed  through  a  sinus  detected  the  wire  sur- 
rounded by  carious  bone.  The  twist  was  still  intact,  but  the  loop  was  loose,  the  bone 
having  become  inflamed,  softened,  and  ulcerated.  Excision  of  the  joint  was  required. 
This  shows  that  occasionally  the  wire  may  excite  irritation  and  thus  lead  to  sei-ious 
results. 

t  Dr.  G.  R.  Fowler  {loc  supra  cit.)  used  large  rubber  drainage-tubes,  whicli  were  no 
removed  till  the  end  of  fourteen  davs. 


■WIRINO    FRACTURES  OF    PATELLA.  915 

and   patience,   will  be  sufficient.     If  an  ana^thetic  is  given,  move- 
ments must  be  made  cautiously,  as  the  patella  has  been  refractured 
on  this  occasion  more  than  once.* 
DifiBculties  in  Wiring  the  Patella. 

1.  Atrophied  surfaces  of  the  fragments,  making  it  difficult  to  refresh 
them  satisfactorily. 

2.  A  very  small  lower  fragment. 

3.  Fragments  embedded  k\  very  firm  filirous  tissue,  fascial,  peri- 
ostea], and  synovial,  or  old  coagulum.  This  condition  will  prevent 
satisfactory  apposition  unless  the  intervening  tissue  be  all  removed. 

In  a  very  interesting  case  recorded  by  Mr.  0.  Ward  (Lancet,  Nov.  1, 
1884)  it  was  found,  on  exploring  the  fragments,  that  the  capsular  tissues 
torn  off  the  lower  fragment  remained  attached  above,  and  hung  like  a 
flap  between  the  fractured  surfaces,  effectually  preventing  their  appo- 
sition. It  is  suggested  that  some  such  complication  may,  in  many 
cases  which  have  been  treated  in  the  usual  way,  cause  the  fragments 
to  fall  apart  as  time  goes  on.  This  is  supported  by  Dr.  Macewen 
(Ann.  of  Surg.,  March,  1887,  p.  178),  who  has  collected  thirteen  cases  of 
transverse  fracture  of  the  patella,  in  which  portions  of  soft  tissue  inter- 
vened between  the  fragments  in  such  a  manner  as  to  render  osseous 
union  an  impossibility. 

4.  A  contracted,  rigid  quadriceps. 

5.  Indipping  skin,  p.  912. 

6.  Multiple  fragments.  This  may  cause  much  difficulty,  especially 
if  it  is  the  lower  and  usualh^  smaller  fragment,  which  is  comminuted. 
If  the  lowest  fragment  is  large  enough  to  bear  wiring,  a  smaller  one 
may  be  removed ;  or  the  wire  may  be  passed  through  the  ligamentum 
patellae.  If  a  case  seemed  to  require  it  I  should  not  hesitate  to  Avire 
smaller  fragments  with  finer  wire,  and  to  pass  one  stout  one  from  the 
highest  to  the  lowest  fragment  (or  ligamentum  patellae),  this  wire 
lying  in  the  joint,  and  passing  under  and  over  one  of  the  smaller  ones. 
To  give  a  firm  support  excision  could  be  resorted  to  as  a  last  resort, 
either  at  the  time  or  later. 

Causes  of  Failure. — These  are  mainly  : 

1.  Inability  to  bring  the  Fragments  together. — Mr.  Turner  (Clin. 
Soc.  Trans.,  vol.  xvii.  p.  41)  mentions  a  case  in  which  the  operation 
was   abandoned,  as   it  was   found  impossible  to  get   the  fragments 


*  In  one  of  Sir  J.  Lister's  cases  (loc.  supra  cit.),  passive  movement  being  employed 
with  "  considerable  force  "  four  weeks  after  the  wiring,  the  rigid  quadriceps  not  yield- 
ing, the  wire  gave  way,  and  the  cicatrix  (a  long  longitudinal  one),  which  had  healed 
save  where  tiie  wire  projected,  opened.  The  joint  was  at  once  washed  out  antisepti- 
cally,  and,  six  days  later,  some  coagula  were  removed  and  the  old  wire  retwisted.  An 
excellent  limb  was  the  result. 


916  OPERATIONS   ON    THE   LOWER   EXTREMITY. 

together  after  wiring  them.    The  patient  was  "  no  better  and  no  worse  " 
eventually. 

2.  Septie  conditions. 

3.  Necrosis  of  a  Fragment. — This  is  a  complication  rather  than  a 
cause  of  failure.  It  is  especially  likely  to  occur  after  severe  com- 
pound fractures,  in  which  the  periosteum  was  much  injured  at  the 
time  of  the  accident.  This  happened  with  the  upper  fragment  in  Dr. 
G.  R.  Fowler's  case  already  quoted.  About  three  months  after  the 
wiring,  this  fragment,  about  the  size  of  a  walnut,  was  removed.  It 
was  now  found  that  "  the  joint  was  perfectly  closed  b}^  a  thick  fibrous 
capsule  underlying  the  necrosed  portion,  connected  to  the  upper 
margins  of  the  now  firmly  united  two  lower  fragments,  and  forming 
a  strong  bond  of  union  between  the  quadriceps  above  and  what 
remained  of  the  patella  below.."  The  resulting  limb  was  useful,  with 
considerable  movement  at  the  knee-joint. 

REMOVAL  OF  LOOSE  BODIES*  FROM  KNEE-JOINT. 

This  is  aiiother  instance  of  an  operation  rendered  safe  and  simple 
by  the  antiseptic  treatment  of  Sir  J.  Lister.  Removal  by  direct 
incision  will  therefore  be  alone  described  here. 

Operation. — The  parts  having  been  kept  at  rest  for  some  days 
before  and  scrupulously  cleansed,  the  foreign  body  is  found,t  if  pos- 
sible, and  retained  in  a  superficial  part  of  the  capsule.  If  it  be  very 
movable,  it  should  be  harpooned  with  a  sharp  needle  at  the  beginning 
of  the  operation.  The  joint  is  then  deliberately  and  sufficiently 
opened.  In  the  traumatic  ease  I  have  mentioned,  the  body  could 
not  be  felt  at  the  time  of  the  operation  \  on  cutting  freely  into  the 

*  The  following  classification  may  be  useful  to  a  surgeon  about  to  operate  for  one  of 
these  bodies  :  (1)  A  thickened  or  indurated  synovial  fringe  which  has  become  pedun- 
culated and  perhaps  detached  ;  (2)  a  fibro-enchondronia  originating  in  those  cartilage 
cells  which  are  naturally  found  in  the  synovial  fringes;  (3)  a  portion  of  articular  car- 
tilage detached  by  injury  (two  years  ago  I  removed  one  of  these  loose  bodies  from  the 
knee-jf)int  of  a  railway  porter  who  came  to  me  for  synovitis,  with  the  history  that  the 
attacks  dated  from  the  time  when  a  cask  wJiich  he  was  moving  had  slipped  and  struck 
the  inner  side  of  his  right  knee-joint) ;  (4)  a  bit  of  cartilage  may,  after  injury,  gradually 
become  detached  by  a  process  of  quiet  necrosis  (Paget) ;  (5)  blood  efiiised  into  a  synovial 
fringe;  (0)  a  mass  of  fibrine ;  (7)  a  detached  osteophyte;  (8)  Mr.  H  Marsh  {Dis.  of 
<7om<s,  p- 182)  mentions  a  case  of  Mr.  Shaw's,,  in  which  a  loose  body  on  removal  was 
found  to  contain  the  point  of  a  needle. 

f  The  patient  is  often  clever  at  this.  Mr.  H.  March  {loc.  supra  cit.)  suggests  that 
it  may  save  disappointment  if  fixing  the  body  has  been  practiced  beforehand  by  the 
assistant  to  whom  tliis  office  is  to  be  intrusted.  In  those  rare  cases  where  the  body 
cannot  be  found,  no  surgeon  familiar  with  antiseptic  details  would  hesitate  to  freely 
cut  into  the  joint  if  the  history  and  the  crippling  of  the  patient  justified  this.  In 
other  cases,  as  occasionally  happens  in  lithotomy,  the  body  is  known  to  be  present, 
but  cannot  be  felt  when  the  patient  is  on  the  table. 


LIGATURE    OF    THE    POPLITEAL    ARTERY.  917 

joint  I  came  down  on  a  tiny  pedunculated  body  attached  to  the  de- 
formed internal  cond3de ;  as  this  was  evidently  too  small  to  be  the 
offending  body,  I  had,  after  removing  it,  to  make  a  prolonged  search 
with  the  finger  before  the  loose  cartilage  was  found  at  the  extreme 
upper  end  of  the  suijra-pateller  pouch.  In  any  such  case  where  the 
body  can  be  felt,  b'lt  not  brought  down,  a  second  incision  should  be 
made  over  it.  Any  bleeding  is  now  finally  arrested,  and  the  wound 
closed  by  sutures  which  carefully  take  up  the  capsule.  If  the  opera- 
tion has  been  a  simple  one,  no  drainage  will  be  required,  effusion 
being  prevented  by  aseptic  precautions  and  firm,  even  bandaging. 
When  the  search  has  been  prolonged,  the  parts  much  interfered  with, 
or  many  bodies  removed,  a  horsehair  drain  or  a  small  tube  must  be 
employed,  either  coming  through  the  wound,  or  through  this  and  a 
counter-puncture  at  the  most  dependent  part  of  the  joint  (p.  914). 

Iodoform  having  been  dusted  on,  dry  antiseptic  dressings  are  ap- 
plied, and  the  limb  put  up  on  a  back  splint 


CHAPTER  IV. 
OPERATIONS  ON  THE  POPLITEAL  SPACE. 

LIGATURE  OF  THE  POPLITEAL  ARTERY. 

Indications. — Extremely  few. 

1.  Stab  or  Punctured  Wound. — Here  the  surgeon  would  only  resort 
to  ligature,  (1)  if  pressure  was  unavailing^  (2)  if  the  patient  insisted 
on  running  the  risk  of  gangrene.;  (3)  it  would  be  well,  if  possible, 
to  get  leave  for  immediate  amputation  if  the  vein  was  found  injured 
also. 

2.  In  some  cases  of  ruptured  popliteal  artery  it  will  be  right  to  ex- 
plore and  see  if  any  other  complication  exists  beyond  the  rupture 
of  the  artery.*  If  there  is  no  injury  to  the  vein,  nerves,  or  the  joint 
(a  very  unlikely  contingency),  the  rupture  may  be  treated  by  double 
ligatures  as  elsewhere.  The  surgeon  must  afterwards  be  prepared  to 
amputate  through  the  lower  third  of  the  thigh  on  the  first  sign  of 
gangrene  appearing.  The  operation  of  ligature  of  the  popliteal 
artery  is  extremely  difficult  here,  owing  to  the  depth  of  the  vessel, 
the  strong  fascia,  the  amount  of  coagulated  blood,  and  the  infiltrated, 
obscured  condition  of  the  parts.  Primary  amputation  will,  as  a  rule, 
be  required  in  cases  of  ruptured  popliteal  artery,  especially  where 
skilled  assistance  and  facilities  for  antiseptic  treatment  are  not  at 

*  Poland,  Guy's  Hosp.  Reports,  third  series,  vol.  vi.  p.  294.. 


9'18  OPERATIONS  ON   THE  LO^YER   EXTREMITY. 

hand.  A  free  incision  will  enable  the  surgeon  to  investigate  the 
amount  of  injury,  and  at  the  same  time  will  relieve  ten&ion  if  an 
attempt  is  made  to  relieve  the  limb.  This  incision  may  form  part  of 
the  amputation  (p..  891). 

3.  The  artery  has  been  wounded  in  the  course  of  an  o&teotomy  of 
the  lower  end  of  the  femur..  In  such,  a  case  the  vessel  should  be 
reached  by  the  incision  given  at  p.  920. 

4.  ''  Possibly  in  a  small  traumatic  aneurism  "  (Sir  W.  MacCormac, 
Ligature  of  Arteries^  p.  109).  If  any  surgeon  is-  inclined  to  perform 
the  old  operation  for  a  ruptured  popliteal  aneurism,  he  should  first 
consult  a  clinical  lecture  on  a  case  of  thi&  kind  by  Mr.  Holmes.  The 
difficulties  which  may  be  expected  are  graphically  described,  and  the 
wisdom  of  amputation  shown. 

Ex-TENT. — From  the  adductor  ojxjning  to  the  lower  border  of  the 
popliteus.. 

Guides. — Behind':  A  line  drawn  from  just  inside  the  inner  ham- 
strings above  to  the  centre  of  the  lower  part  of  the  popliteal  space.  In 
Front :  The  tendon  of  the  adductor  magnus. 

Relations  (in  the  popliteal  space) : 

In  Front. 
Skin,;  fasciae  ;.  small  sciatic  nerve  above  ;  short  saphena  vein 

and  extenal  saphena  nerve  below. 
Fat;  glands. 
Semi-membranosus  above  \  gastrocnemius,  plantaris,  soleus, 

below. 
Internal  popliteal  nerve  ;.  popliteal  vein,  outside  above,  inside 

below,  exactly  over  the  artery  in  the  centre  of  the  space. 
Branch  of  obturator  above.. 

Outside.  Insid'E. 

Biceps,  above  ;  gastrocnemius-,.  Semi-membranosus,  above  ; 

and  plantaris,.  below..  gastrocnemius,  below. 

Popliteal'  artery. 

Behind. 
Femur. 

Posterior  ligainent.. 
Popliteus^ 

Collateral  Circulation. 

Above.  Below. 
Anastomotica  magna,  superior  Inferior   articular,   and   re- 
articular,  descending  branch,  with          current     from     anterior 
of  external  circmuflex.  tibial. 


LIGATURE   OF    THE    POPLITEAL    ARTERY. 


919 


Operations  (Figs.  172,  173). — The  artery  may  be  tied  in  three 
places.  A.  At  the  upper  part  of  the  popliteal  space.  B.  At  the  lower 
part  of  the  popliteal  space.  C.  From  the  front,  at  the  inner  side  of  the 
limb.  For  the  sake  of  experience,  all  should  be  practiced  on  the 
dead  body. 

A.  At  the  Upper  Part  of  the  Popliteal  Space  (Fig.  172).— The 
patient  being  rolled  two-thirds  on  to  his  face,  and  the  limb  at  first  ex- 

Fig.  172. 


The  artery  lies  emberied  in  fat.  Above  it  are  some  of  the 
fibres  of  the  adductor  magnus.  In  tlie  upper  angle  of  the 
wound  the  sartorius  has  been  drawn  down. 

Above,  the  artery  is  shown  under 
cover  of  the  semi-membranosus. 
The  small  sciatic  has  been  drawn 
aside  with  a  blunt  hook.  Below, 
the  vessel  is  exposed  just  above 
the  heads  of  the  gastrocnemius. 
The  internal  popliteal  nerve  is  seen 
below  outside  the  artery  jnst  be- 
fore it  crosses  to  the  inner  side. 

tended,  an  incision  3i  inches  long  is  made,  in  the  line  of  the  vessel, 
along  the  outer  margin  of  the  semi-membranosus,  and  then  down- 
wards and  outwards  to  the  centre  of  the  space.  The  small  sciatic 
nerve,  if  seen,  should  be  drawn  to  one  side  ;  the  deep  fascia  is  then 
freely  opened  up,  and  the  pulsation  or  the  artery  felt  for  at  the  inner 
margin  of  the  semi-membranosus.  The  nerve  is  generally  seen  first, 
and  this  and  the  vein  are  to  be  drawn  to  either  side  with  blunt  hooks. 
The  needle  should  be  passed  from  the  vein.  A  good  deal  of  loose  fat 
is  usually  in  close  contact  with  the  vessels,  and  is  liable  to  be  a  source 


920  OPERATIONS   ON   THE    LOWER   EXTREMITY. 

of  trouble  wherever  the  artery   is  ligatured,  especially  in  the  dead 
subject. 

B.  At  the  Lower  Part  of  the  Popliteal  Space  (Fig.  173).— The 
limb  being  in  the  same  j>osition,  an  incision  82  inches  long  is  made, 
in  the  line  of  the  artery,  from  the  centre  of  the  popliteal  space  to  the 
junction  of  the  upper  and  middle  thirds  of  the  back  of  the  leg. 
The  external  saphena  vein  and  its  nerve  being  avoided,  the  deep 
fascia  is  freely  opened  and  the  limb  flexed.  The  exact  interval 
between  the  heads  of  the  gastrocnemius  is  next  sought  for.  The  fol- 
lowing structures  may  now  be  met  with  overlying  the  artery,  and 
must  be  drawn  aside — viz.,  the  plantaris,  the  sural  arteries  which  run 
down  on  the  vessel,  and  the  posterior  tibial  nerve,  which  is  often 
given  off  as  high  as  this.  The  popliteal  vein  now  lies  to  the  inner 
side,  together  with  the  popliteal  nerve,  which  is  superficial  to  it,  if  this 
has  not  given  off  its  branches.  These  structures  should  be  drawn  to 
either  side,  and  the  needle  passed  as  is  convenient. 

C.  From  the  Front,  at  the  Inner  Side  (Fig.  173). — This  opera- 
tion might  be  useful  in  cases  where  hiemorrhage  recurs  after  oste- 
otomy at  the  lower  end  of  the  femur. 

The  following  account  is  taken  from  Sir  W.  MacCormac  (Ligature  of 
Arteries,  p.  110) :  "  Flex  tlie  knee  and  place  the  limb  on  the  outer  side. 
Make  an  incision  3  inches  long  immediately  behind  and  parallel  to 
the  tendon  of  the  adductor  magnus  downwards  from  the  junction  of 
the  middle  and  lower  thirds  of  the  thigh.  Divide  the  skin,  superficial 
and  deep  fasciae,  avoid  the  long  saphenous  nerve,  seek  the  tendon  of 
the  adductor  magnus,  draw  it  forwards  and  the  hamstring  tendons 
backwards.  The  artery  will  then  be  found  surrounded  by  fatty 
areolar  tissue.  The  nerve  and  vein  do  not  necessarily  come  into  view, 
being  on  the  external  asj^ect  of  the  vessel." 


CHAPTER  V. 

OPERATIONS  ON  THE  LEG. 

LIGATURE  OF  POSTERIOR  TIBIAL  ARTERY.  —  LIGA- 
TURE OF  ANTERIOR  TIBIAL  ARTERY.-LIGATURE 
OF  PERONEAL  ARTERY.— AMPUTATION  OF  LEG.— 
OPERATION  FOR  NECROSIS.— TREATMENT  OF  COM- 
POUND FRACTURE. 

LIGATURE  OF  THE  POSTERIOR  TIBIAL  ARTERY. 

Indications. — Very  rare. 

i.   Chiefly   Wounds. — Mr.    Cripps,*   in   a   very   interesting   paper, 

*  St.  Barthol.  Hosp.  Reports,  vol.  xi.  p.  94 ;  Diet,  of  Surg.,  vol.  ii.  p.  626. 


LIGATURE    OF    THE    POSTERIOR    TIBIAL. 


921 


divides  up  the  sources  of  haimorrhage  from  the  upper  two-thirds  of 
the  posterior  tibial  into  (1)  hsemorrhage  after  amputation;  (2)  haemor- 
rhage from  injury  to  the  vessels  in  continuity. 

1.  Haemorrhage  after  Amputation. — This  is  usually  due  to  a  dis- 
eased condition  of  the  vessels,  and  to  the  fact  that  the  vessels,  lying 
between  the  bones,  are  now  especially  difficult  to  take. up.  If  from 
their  constantly  breaking  away  it  is  found  imj)ossible  to  deal  with 
them,  the  limb  sliould  at  once  be  amputated  above  the  knee.  If  the 
haemorrhage  occurs  later  on,  well  adjusted  pressure  (p.  877)  should 
be  carefully  tried,  aided  or  followed  by  ligature  of  the  femoral  or  by 
amputation  higher  up. 

2.  Hteniorrhage  from  Wounds  of  the  Tibials  in  Continuity. — Three 
chief  causes  may  lead  to  this:  (a)  Incised  wounds,  ib)  Punctured 
wounds,  (c)  Wounds  other  than  punctured  or  incised.  Four  methods 
of  treatment  are  open  to  the  surgeon — viz.,  (a)  Pressure  and  band- 
aging. (6)  Ligature  of  both  ends  of  the  vessel,  (c)  Ligature  of  the 
femoral,     (d)  Amputation. 

(a)  Incised  Wound. — If  this  is  seen  soon  after  its  infliction  the  bleed- 
ing-point should  be  sought  for  and  tied,  the  wound  being  enlarged, 

Fig.  174. 


''*%W/''^^''''     'l:^'-  ^ 


Ligature  of  the  posterior  tibial  artery  at  tlie  inner  ankle.    The  incisions  in  amputation  of  the 
great  toe  at  the  metatarso-phalangeal  and  the  inter-phalangeal  joints  are  also  shown. 


if  needful.  If  sloughing  and  extravasation  of  blood  have  taken 
place,  amputation  will  probably  be  the  wiser  course,  though  if  the 
patient  decide  to  run  the  risk,  an  attempt  may  be  made  to  save  his 
limb  by  making  free  incisions,  providing  drainage,  j^lugging  the 
wound  (rendered  as  far  as  may  be  aseptic  with  irrigation  and  iodo- 
form) with  dry  gauze,  bandaging  evenly  and  firmly,  and  tying  the 
femoral  in  Hunter's  canal. 


922  OPERATIONS   ON    THE    LOWER    EXTREMITY. 

(b)  Punctured  Wound. — If  this  is  deep,  and  the  vessel  injured  un- 
certain, the  question  of  treatment  is  a  ver}'  serious  one.*  Mr.  Cripps 
shows  that,  in  the  majority  of  instances,  pressure  deserves  a  fair  and 
thorough  trial.  If  it  is  useless  or  prejudicial  to  other  treatment, 
either  the  femoral  must  be  tied  or  the  wound  enlarged  to  secure  the 
wounded  vessel.  Between  these  operations  the  features  of  the  par- 
ticular case  must  decide.  If  pressure  is  made  use  of  it  should  be 
applied  methodically  and  with  intelligent  purpose  (p.  877),  and  so 
that  it  needs  no  alteration  or  repetition. 

(c)  Wounds  other  than  Punctured  or  Incised — viz.^  Injury  to  the  Vessel 
from  Fracture  or  Gunshot  Wound. — In  many  cases  conditions  will  be 
present  which  will  call  for  amputation — viz.,  the  severity  of  the 
crush;  the  extent  of  the  comminution;  injury  to  the  nerves  or  to 
both  arteries,  as  evidenced  by  tlie  condition  of  the  foot ;  ajid  the  age  or 
the  health  of  the  patient.  In  most  of  these  cases,  as  an  attempt  to  find 
the  vessel  involves  great  difficulty  and  danger,  and  the  probabilities  of 
success  diminish  as  the  interval  between  the  infliction  and  treatment 
of  the  injury  increases,  ligature  of  the  femoral  would  be  less  hazardous 
than  any  interference  with  the  wound.  But  amputation  will  frequently 
be  needed.  The  above  remarks  apply  to  compound  fractures ;  an 
instance  of  successful  ligature  of  a  lacerated  femoral  coexisting  with 
a  simple  fracture  of  the  leg  is  given  at  p.  872. 

ii.  Small  traumatic  aneurisms. 

iii.  The  posterior  tibial  may  be  tied  low  down,  together  with  the 
dorsalis  pedis,  for  certain  wounds  of  the  sole  or  for  some  vascular 
growths  of  the  foot. 

Line  and  Guide. — A  line  drawn  from  a  point  at  the  lower  part  of 
the  centre  of  the  popliteal  spacef  to  one  midway  between  the  tendo- 
Achillis  and  the  internal  malleolus. 

Relations. — These  differ  according  as  the  vessel  is  tied — (A)  in 
the  middle  of  the  leg,  (B)  in  the  lower  third  of  the  leg,  (C)  at  the 
inner  ankle. 

A.   Relations  in  the  Middle  of  the  Leg  : 

Superficial. 

Skin ;  fasciae ;  branches  of  saphenae  veins  and  nerves. 
Gastrocnemius  ;  soleus ;  plantaris. 

*  Where  the  wound  has  passed  obliquely,  Dupuytren's  words  should  be  remem- 
bered. They  refer  to  haemorrhage  from  the  calf  caused  by  a  pistol-bullet.  "Should  a 
ligature  be  placed  on  the  ends  of  the  divided  vessel  ?  But  what  were  those  vessels? 
Was  it  the  anterior  or  posterior  tibial,  or  the  peroneal  or  the  popliteal?  Was  it 
several  of  them  at  the  same  time  ?     Should  they  be  attacked  before  or  behind  ?  " 

t  This  point,  representing  the  lower  border  of  the  popliteus,  would  be  about  2^ 
inches  below  the  knee-joint. 


LIGATURE    OF   THE   POSTERIOR   TIBIAL.  923 

Special  fasciae ;  transverse  branches  of  vena  comites ; 
tendinous  origin — arch  of  soleus  (above). 

Outside,  Inside. 

Vena  comes.  Vena  comes. 

Posterior  tibial  nerve  Posterior  tibial  nerve 

which   has   crossed  Posterior  tibial.  (above). 

above      from      the 

inner  side. 

Beneath. 

Flexor  longus  digitoriim. 
Tibialis  posticus. 

B.  Relations  in  Lower  Third  of  Leg: 

Superficial. 
Skin;  fascia;  superficial  veins  and  nerves. 

Outside.  Inside. 

Vena  comes.  Vena  comes. 

Posterior  tibial  nerve.  Posterior  tibial. 

Tendo-Achillis. 

Beneath. 

Flexor  longus  digitorum. 
Tibia. 

C.  Relations  at  Inner  Ankle  : 

Superficial. 

Skin  ;  fascise  ;  branches  of  internal  saphena  vein 

and  nerve. 
Internal  annular  ligament. 

Outside,  Inside. 

Vena  comes.  Vena  comes. 

Flexor  longus  pollicis.  Posterior  tibial.  Flexor  longus  digi- 

Posterior  tibial  nerve.  torum. 

Beneath. 
Internal  lateral  ligament. 


924 


OPERATIONS    ON    THE    LOWER    EXTREMITY'. 


Fia.  175. 


gr^'vvff^ 


Operation  in  Middle  of  Leg  (Fig.  175). 

The  parts  being  cleansed,  the  knee  flexed,  and  the  limb  supported 
on  its  outer  side,  the  surgeon,  standing  or  sitting  on  the  inner  side, 
makes  an  incision  3^  inches  long,  parallel  with  the  centre  of  the 
inner  border  of  the  tibia ;  and  2  or  |  inch  behind  it,  according  to  the 
size  of  the  limb.  This  incision  divides  skin  and  fiiscise.  If  the  in- 
ternal saphenous  vein  is  met  with,  it  must  be  drawn  aside  with  a 
strabismus  hook;  any  of  its  branches  may  be  divided  between  two 
chromic-gut  ligatures.     The  deep  fascia  is  then  freely  slit  up,  and  the 

inner  edge  of  the  gastrocnemius  defined 
and  drawn  backwards.  This  will  expose 
the  soleus,  the  tibial  attachment  of  which 
is  to  be  cut  through,  any  sural  artery 
being  at  once  secured.  The  incision 
through  the  soleus  should  be  3  inches 
long  and  quite  h  inch  from  the  tibia;  as 
the  fibres  are  divided  the  central  mem- 
branous tendon  will  come  into  view,  and 
must  not  be  confused  with  the  special 
deep  fascia  or  intermuscular  septum  over 
the  deep  flexors.  Usually,  before  this 
comes  into  view,  some  additional  fibres 
have  to  be  divided.  When  this  is  done 
the  above  special  fascia  must  be  iden- 
tified stretching  between  the  bones.  The 
wound  must  be  carefully  dried,  and  well 
opened  out  with  retractors,  and  exposed 
witli  a  good  light  at  this  stage.  The  deep 
fascia  being  opened  carefully,  the  nerve 
usually  comes  into  view  first,  the  artery 
The  position  of  Uie  incision  is  shown  lying  a  little  deeper  and  more  internal. 
:°M:hSrp*:.ra  '41;°  :re°  The  ve„*  coxites  should  be  separated  as 

The  inner  border  of  the  gastrocnemius  far  aS  pOSSiblc,  but  rather  than  pUncturC 

Is  seen  to  the  right  beneath  the  cut  fat.  ^j^g^^    ^^^^     ^^^^gg     hemorrhage    at     this 
One  of  the  edges  of  the  cut  soleus  is  ^        ^  ^ 

shown   retracted.     One   of  the    vena;  stage,  Or  Wastc  time,  the   SUrgeon   should 

comites  is  shown  internal  to  the  artery,  ^g    them    in.        The     needle    should     be 
the  nerve  lying  to  its  outer  side.  ...  ,,  m       j'     -tj.    x 

passed  from  the  nerve,  lo  taciiitate 
this  the  knee  should  be  well  flexed,  and  the  foot  also  flexed  down- 
wards so  as  to  relax  the  muscles  thoroughly.  The  ligature  will  lie 
below  the  peroneal  artery. 

Operation  in  Lower  Third  of  Leg.— The  limb  and  the  operator 
being  in  the  same  position  as  at  p.  924,  an  incision,  2J  inches  long, 
is  made  through  skin  and  fascia,  parallel  with  the  inner  border  of  the 


LIGATURE   OF   THE    ANTERIOR    TIBIAL.  925 

tibia,  and  midway  between  it  and  the  tendo-Achillis ;  after  the  deep 
fascia  has  been  opened,  another  layer,  tying  down  the  deep  flexor 
tendons,  will  require  division.  The  artery  here  lies  between  the  flexor 
longus  digitoruni  and  pollicis,  surrounded  by  venae  comites.  The 
needle  should  be  passed  from  the  nerve,  which  lies  external.  If  the 
incision  is  made  too  high,  some  of  the  lovvest  fibres  of  the  soleus  will 
require  detaching  from  the  tibia,  if  too  low  the  internal  annular  liga- 
ment would  be  opened.  The  sheaths  of  the  flexors  (their  synovial 
investment  commences  about  1?  inch  above  the  internal  malleolus) 
should  not  be  interfered  with. 

Operation  at  the  Inner  Ankle  (Fig.  174).— The  limb  and 
operator  being  placed  as  before,  a  curved  incision,  2  inches  long,  is 
made,  f  inch  behind  the  internal  malleolus.  Skin  and  fiisciae  being 
divided,  and  any  branches  of  the  internal  saphena  vein  tied,  the  in- 
ternal annular  ligament  is  divided  and  the  artery  found,  closely  sur- 
rounded wdth  its  veins.  Tlie  nerve  lies  externally,  and  the  needle 
should  be  passed  from  it.  The  artery  is  so  superficial  here,  that  the 
veins  can  be  easily  separated.  The  nerve  has  occasionally  bifurcated 
higher  up. 

LIGATURE  OF  THE  ANTERIOR  TIBIAL. 

Indications. — These  are  very  few,  and  resemble  so  closeh'  those 
already  given  for  the  posterior  tibial — viz.,  wounds  and  traumatic 
aneurism — that  there  is  no  need  to  go  into  them  again  here. 

In  the  course  of  1887,  I  had  occasion  to  tie  the  anterior  tibial  in  its 
lower  third  for  profuse  haemorrhage  from  a  compound  fracture  not 
arrested  by  pressure.  There  was  a  compound  comminuted  fracture 
of  the  right  leg  in  the  lower  third  from  a  fall  of  4  cwt.  upon  the  limb. 
The  upper  end  of  the  artery  was  found  with  some  difliculty,  owing  to 
the  pulped-up  condition  of  the  soft  parts.  Having  failed  to  find  the 
lower  end,  I  was  about  to  expose  the  dorsalis  pedis,  and,  trusting  to 
antiseptic  precautions,  trace  this  up  to  the  anterior  tibial,  when,  an 
urgent  strangulated  hernia  being  admitted  I  plugged  the  wound,  all 
the  undermined  parts  being  previously  laid  freely  open.  No  recur- 
rence of  bleeding  took  place,  and  the  man  (aged  forty-four)  made  an 
excellent  recovery,  aided  by  his  temperate  life  and  patient  ways,  the 
freedom  with  which  the  wound  was  laid  open,  this  preventing  all 
retention  of  discharges,  the  use  of  dry  gauze  dressings  only  changed 
at  rare  intervals,  and,  not  least,  the  fact  that  iodoform  was  thoroughly 
dusted  in. 

Dr.  Shepherd,  of  Montreal  (Annals  of  Surgery,  No.  1,  p.  7),  gives 
another,  but  more  ditficult,  case  in  which  the  com2:»ound  fracture  was 


926  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

about  the  junction  of  the  middle  with  the  upper  third  of  the  leg.  The 
bleeding  was  first  arrested  by  pressure,  on  the  fourth  day  a  traumatic 
aneurism  appeared.  The  artery  was  exposed  with  difficulty,^  and 
found  23artly  divided,  two  ligatures  were  applied,  and  the  patient  made 
a  good  recovery. 

Line  and  Guide. — From  a  point  midway  between  the  head  of  the 
fibula  and  the  outer  tuberosity  of  the  tibia  to  the  centre  of  the  front 
of  the  ankle-joint.     The  outer  edge  of  the  tibialis  anticus. 

Relations  : 

Superficial. 

Skin ;  fasciae ;  cutaneous  branches  of  saphenous  veins 
and  nerves,  and  (below)  musculo-cutaneous  nerve. 

Tibialis  anticus  and  extensor  longus  digitorum  (above), 
overlapping. 

Tibialis  anticus  and  extensor  longus  pollicis  (below), 
overlapping. 

Outside.  Anterior  tibial  artery.  InsIDE. 

Extensor  longus  digitorum  (above).  Tibialis  anticus. 

Extensor  longus  pollicis  (below).  Vein. 

Anterior  tibial  nerve. 
Vein. 

Beneath. 

Interosseus  membrane. 

Operation  at  the  Junction  of  the  Upper  and  Middle  Third 
of  Leg. — The  knee  being  flexed  and  the  limb  supported  upon  its 
inner  side,  the  surgeon  having  defined  if  possible  the  outer  edge  of  the 
tibialis  anticusy  sits  or  stands  on  the  outer  side  of  the  patient,  and 


*  Dr.  Shepherd  points  out  that,  the  injury  to  the  vessel  being  just  in  front  of  the 
place  where  it  pierces  the  interosseous  membrane,  if  the  artery  had  been  completely 
torn  through,  it  would  have  retracted  through  the  opening,  and  ligature  would 
have  been  impossible.  Mr.  Page  (Lancet,  1887,  vol.  i.  p.  522)  gives  a  case  of  a  traumatic 
aneurism  of  ten  weeks'  duration,  after  a  stab,  at  the  junction  of  the  middle  and 
lower  third  of  the  leg.  The  swelling  had  been  poulticed  and  opened,  with  the 
result  of  haemorrhage.  Mr.  Page,  on  clearing  out  the  clots  and  opening  up  tlie 
swelling,  was  unable  to  find  the  anterior  tibial  artery.  Hipmorrhage  recurring,  the 
leg  was  amputated.     The  patient  recovered. 

+  The  patient  may  put  this  into  action  just  before  taking  the  aupesthetic. 


LIGATURE   OF   THE    ANTERIOR   TIBIAL. 


927 


Fig.  176. 


makes  an  incision  about  4  inches  long  in  the  line  of  the  artery,  begin- 
ning about  2  inches  below  the  head  of  the  tibia.  This  incision  should 
lie  (if  the  edge  of  the  muscle  has  not  been  marked 
out)  4  to  1  inch — according  to  the  size  of  the  leg — 
from  the  crest  of  the  tibia,  and  should  expose  the 
deep  fascia  carefully  so  that  the  white  line  which 
marks  the  desired  inter-muscular  septum  may  be 
looked  for.  This  line  is  often  whitish-yellow,  and 
varies  much  in  distinctness.  If  there  is  any  diffi- 
culty in  finding  it,  any  bleeding  points  must  be 
secured,  and  the  deep  fascia  slit  up  over  the  line 
of  the  artery,  and  the  finger-tip  inserted  to  feel  for 
the  sulcus  between  the  muscles.  A  third  aid  is 
almost  constant,  and  that  is  a  small  muscular 
artery*  which  comes  up  between  the  tibialis  and  the 
extensor  longus  digitorum.  The  sulcus  being  found 
between  the  muscles  (without  tearing  them),  they 
are  separated  with  the  handle  of  a  scalpel  or  a 
steel  director,  and  retractors  inserted,  the  outer  one 
being  hooked  over  the  fibula.  If  the  limb  is  a  very 
muscular  one  the  deep  fascia  should  be  nicked 
transversely  at  the  upper  and  lower  extremities  of 
the  wound,  and  the  parts  more  relaxed  by  bending 
the  knee  more  and  pressing  the  foot  upwards.  The 
finger  now  directed  toward  the  interosseus  space 
feels  for  the  artery  deep  down  in  the  bottom  of  the 
wound.  The  nerve  should  be  drawn  to  the  outer 
side.  If  much  trouble  is  met  with  in  separating 
the  venae  comites  they  may  be  included. 

-pv-  !•  •  -\    J  Till  1  lying  between    the    dis- 

Dramage  bemg  provided,  and  all  haemorrhage  p,^,^^  tibialis  a.uicus 
stopped,  the  wound  is  slightly  dusted  with  iodo-  and  extensor  longus 
form,  the  muscles  united  with  one  or  two  chromic-  f 'sj^™'"- .  t^^  muscu- 

'  lar  brancli  is  sliown,  but 

gut  sutures,  and  the  wound  closed  and  the  limb  kept  rather  too  large, 
raised  and  flexed. 

Operation  at  the  Junction  of  the  Lower  and  Middle  Third 
of  Leg. — An  incision  about  25  inches  long  is  made  in  the  line  of  the 
artery,  in  the  upper  part ;  this  incision  Avill  be  about  1  inch  from  the 
tibia.  The  white  line  and  the  interval  between  the  tibialis  anticus 
and  the  extensor  prbprius  pollicis  are  both  looked  and  felt  for.  The 
deep  fascia  being  divided  and  the  muscles  relaxed  and  tetracted,  the 


The  anterior  tibial  is 
seen  with  one  of  its  veins 


*  This  is  pointed  out  by   Mr.  C.  Heath  {Oper.  Surg.,   p.  47).     I  have  found  the 
same  thing  luo.st  helpful  in  tiie  ligature  of  the  ulnar  in  the  middle  tiiird  (p.  56). 


928  OPERATIONS   OX   THE   LOWER   EXTREMITY. 

artery  is  found  surrounded  by  its  venre  comites.    The  needle  must  be 
passed  from  without  inwards. 

LIGATURE  OP  THE  PERONEAL  ARTERY. 

Indications. — As  tliese  are  extremely  few,  and  as  in  the  case  of  a 
wound  of  the  vessel  (which  is  very  rarely  met  with)  the  best  course 
would  be  to  enlarge  the  wound,  any  formal  operation  for  its  ligature 
need  only  be  very  briefly  described. 

Relations. — The  peroneal  artery  comes  off  from  the  posterior  tibial 
about  1  inch  below  the  popliteus,  descends  at  first  parallel  with  this 
artery  but  se2:>arated  from  it  by  the  posterior  tibial  nerve ;  it  then 
passes  outwards  towards  the  fibula  and  runs  down  between  this  bone 
and  the  flexor  longus  pollicis.  In  the  upper  part  of  its  course  it  lies 
upon  the  tibialis  posticus,  and  is  covered  by  the  soleus. 

Operation. — To  tie  the  artery  when  no  wound  is  present  to  guide 
the  surgeon,  an  incision,  3  inches  long,  should  be  made  along  the 
posterior  border  of  the  fibula  with  its  centre  at  the  junction  of  the 
upper  and  middle  thirds  of  the  legs.  The  gastrocnemius  being  drawn 
aside,  and  the  soleus  separated  from  its  attachment  to  the  fibula,  the 
special  deep  fascia  is  slit  up  and  the  artery  sought  for  close  to  the 
fibula. 

AMPUTATION  OF  THE  LEG. 

Different  Methods. 

1.  Lateral  Flaps  (Fig.  177). 

2.  Teale's  Rectangular  Flaps  (Figs.  178,  179,  180). 

3.  Antero-posterior  Flaps  of  Skin. 

4.  Antero-posterior  Flaps,  Anterior  of  Skin,  Posterior  by 

Transfixion  of  Muscle. 

5.  Circular. 

I  shall  only  describe  the  first  two,  as  they  will  be  found  adapted  to 
all  emergencies,  and  to  be  devoid  of  the  disadvantages  of  the  others. 

1.  Lateral  Skin  Flaps,  with  Circular  Division  of  the 
Muscles,  etc. — This  is,  I  believe,  a  method  not  well  known  beyond 
Guy's  and  those  who  have  been  taught  there.  It  will  not  only  be 
found  most  convenient  at  the  time,  but  it  also  gives  very  satisfactory 
results  afterwards.  The  blood-supply  is  well  and  equally  distributed 
to  the  lateral  flaps,  one  can  be  conveniently  cut  longer  than  the  other, 
and  they  are  more  easily  siiaped  and  dissected  up  than  antero-posterior 
skin  flaps,  while  no  mass  of  muscle  is  left  to  drag  away  from  and  ex- 
pose the  bones,  as  in  the  antero-posterior  flajis,  with  the  anterior  of 
skin  and  the  posterior  by  transfixion. 


AMPUTATION    OF    THE    LEG. 


929 


Fig.  177. 


Operation  (Fig.  177).— The  femoral  arter}^  being  commanded, 
the  leg  brought  over  the  table,  and  the  damaged  or  diseased  parts 
wrapped  in  carbolized  lint  so  as  to  give 
the  assistant  a  firm  hold  and  also  to  pre- 
vent his  soiling  the  flaps  later  on,  the 
opposite  ankle  is  tied  to  the  table.  The 
surgeon  standing  to  the  right  of  the  limb 
places  his  left  index  on  the  crest  about  an 
inch  below  the  tubercle,  and  his  thumb  at 
a  corresponding  point  behind  in  the  centre 
of  the  limb.  Looking  over  he  inserts  his 
knife  close  to  the  thumb  and  cuts  on  the 
side  of  the  limb  farthest  from  him  a  lateral 
flap  broadly  oval  in  shape  and  3  inches 
long,  ending  at  the  index  finger,  from 
which  point,  without  removing  the  knife, 
a  similar  flap  is  marked  out  ending  on  the 
back  where  the  first  began.  The  flaps  are 
now  dissected  up  of  skin  and  fasciae,  and 
the  muscles  all  cut  through  with  a  circular 
sweep  of  the  knife  at  the  intended  point 
of  bone-section,  this  sweep  being  repeated 
two  or  three  times  till  the  soft  parts  are  all 
clearly  severed.  The  interosseous  mem- 
brane is  next  divided,  so  that  it  shall  not 
be  frayed  by  the  saw,  and  with  one  final, 
firmly  drawn,  circular  sweep  the  perios- 
teum is  grooved  for  the  saw."''^  This  is  then  applied  with  the  follow- 
ing prccai«^ions.  The  position  of  the  fibula  behind  the  tibia  and  its 
much  smaller  size  must  be  remembered  lest  it  be  splintered.  This 
may  be  avoided  by  rolling  the  leg  well  over  on  to  the  inner  or  outer 
side  as  the  case  may  be,  and  placing  the  heel  of  the  saw  well  down 
on  the  outer  side  so  as  to  start  the  section  of  the  bones  simultaneously, 
and  thus  ensure  complete  division  of  the  fibula  before  the  tibia.  This 
object  may  also  be  effected,  if  the  leg  is  held  in  the  ordinary  position, 
by  applying  the  saw  to  the  tibia,  and  remembering,  when  this  bone 
has  been  sawn  half  through,  to  depress  the  handle,  and  thus  complete 
the  section  of  the  bones  simultaneously.  In  either  case  the  saw 
should  be  used  lightly  and  quickly,  with  the  whole  length  of  the 
blade,  and  without  jamming.     As  the  sharp  projecting  angle  of  the 


*  Nowadays,  with  antiseptic  precautions,  the  old  need  of  periosteal  flaps — viz.,  to 
keep  pus,  etc.,  out  of  the  diploe  and  medullary  canal — is  no  longer  present.  Further- 
more, these  flaps  are  very  difficult  to  raise,  unless  inflamed,  especially  in  the  thin 
periosteum  of  adults. 


59 


930 


OPERATIOXS    ON    THE   LOWER    EXTREMITY. 


crest  tends  to  come  through  to  the  anterior  angle  of  the  flaps,  this 
should  be  sawn  off  obliquely  either  after  the  bones  are  sawn,  or 
by  starting  the  saw  first  ol>liquely  about  la  inch  above  the  place 
where  the  bones  are  to  be  sawn  transversely. 

Teale's  Amputation  by  Rectangular  Flaps  (Figs.  178,  179, 
180), 

Advantages. — 1.  The  covering  for  the  bones  is  ample,  and  the  flaps 
come  together  without  tension.*     2.  The  way  in  which  flaps  are  united 

Fig. 178. 


(Teale.) 

favors  drainage  during  healing,  and  provides  a  scar  well  out  of  the" 
way  of  pressure.     3.  The  stump  bears  pressure  well. 

Disadvantages. — 1.  It  is  an  expensive  method,  involving  a  high  sec- 
tion of  the  bones.  2.  The  long  anterior  flap  may  slough.  3.  If  per- 
formed with  the  accuracy  of  its  introducer,  it  involves  more  time  than 
that  by  lateral  flaps  (p.  928),  and  is,  thus,  not  suited  to  cases  of 
shock. 

Operation. — The  preparatory  steps,  and  the  jjosition  of  the  opera- 
tor and  patient,  are  as  at  p.  929.  The  surgeon  having  measured  the 
circumference  of  the  liml)  at  the  spot  where  he  intends  to  saw  the 
bones,  and  placing  here  his  left  index  and  thumb  on  the  tibia  and 
fibula,  traces  out  a  long  rectangular,  anterior  flap  which  is  to  be,  both 
in  its  length  and  breadth,  equal  to  half  the  above  cirr-umference.f  In 
tracing  this  flap  the  incision  starts  from  the  index  finger,  runs  down 
along  the  bone  farthest  from  the  surgeon  for  4-1  inches  (if  the  circum- 
ference at  the  site  of  bone  section  is  9  inches),  then  crosses  the  limb, 

*  Save  when  infiltrated;  the  difficnlty  of  getting  the  anterior  flap  into  position  is 
then  often  considerahle. 

f  In  the  lower  tliird,  where  the  leg  tapers  quickl}',  care  must  be  taken  to  keep  this 
flap  of  the  same  width  below  as  it  is  above. 


AMPUTATION    OF    THE    LEG. 


931 


cutting  all  the  structures  down  to  the  bones— this  end  of  the  flap 
being  also  41  inches  wide — and  then  travels  up  along  the  opposite 
bone  to  the  surgeon's  thumb.  The  anterior  flap  is  then  dissected  up, 
partly  with  the  knife — e.g.,  on  the  inner  side,  where  the  scanty  cover- 

Fig.  179. 


ings  must  be  raised  as  thick  as  possible  and  without  scoring,  parti}'- 
with  the  knife  and  partly  with  the  finger  on  the  outer  aspect,  where 
the  extensors,  anterior  tibial  vessels  and  nerves  must  be  stripped  up, 
uninjured,  from   the  interosseous   membrane.      The   posterior   flap, 


Fig.  180. 


(Teale.) 


which  has  been  previously  marked  out  fully  i  in  length  of  the  ante- 
rior, is  now  cut  by  the  surgeon  looking  over  the  limb  and  passing 
his  knife  beneath  it,  and  cutting  everything  down  to  the  bones.  It  is 
next  raised  as  high  as  the  point  where  the  bones  are  to  be  sawn.    The 


932  OPERATIONS    ON   THE    LOWER    EXTREMITY. 

interosseous  membrane  and  the  bones  are  then  attended  to  with  the 
precautions  given  at  p.  929. 

The  vessels  being  secured  and  drainage  provided,  the  anterior  flap 
is  folded  over  the  bones  (care  being  taken  not  to  double  it  too  sharply), 
its  cut  end  stitched  to  the  cut  end  of  the  posterior  flap,  and  the  por- 
tion folded  below  the  bones  stitched  to  that  folded  above  them  (Fig. 
180). 

SEQUESTROTOMY. 

As  the  removal  of  necrosed  bone  is  most  frequently  required  in  the 
leg,  the  above  operation  will  be  described  here. 

Indications. — The  question  will  often  arise  as  to  whether  the  case 
is  ripe  for  operation.  The  chief  points  bearing  upon  this,  and  the 
looseness  of  the  sequestrum,  are  (1)  The  time  that  has  elapsed  since 
the  beginning  of  the  illness ;  thus,  two  to  three  moTiths  will  probably 
be  required  in  the  case  of  the  tibia,  but  more  likely  six  in  that  of  the 
femur  ;  (2)  the  age  and  general  health*  of  the  patient.  The  younger 
the  patient,  and  the  more  vigorous  his  vitality,  the  more  rapidly  will 
the  sequestrum  become  detached;  (3)  the  size  of  the  sequestrum. 
The  larger  and  more  total  the  sequestrum,  the  slower  will  be  the  pro- 
cess ;  (4)  the  feel  of  the  sequestrum.  When  steel  probes  announce  this 
to  be  dr}?^,  hard,  and  ringing,  exploration  is  justified,  especially  if  the 
sequestrum  can  be  felt  to  be  loose  or  depressed  by  the  probe ;  (5) 
the  size  and  amount  of  the  new  shell  of  bone.  The  more  distinct 
this  is,  the  more  probable  is  it  that  the  process  of  sejDaration  is  com- 
plete. 

Operation.! — This  should  be  always  conducted  antiseptically, 
with  the  spray,  when  practicable,  or  with  careful  irrigation  with  a 
solution  of  mercury  perchloride  (1  in  2000),  and  for  these  reasons — 
(a)  to  prevent  any  risk  of  setting  up  septic  osteo-myelitis ;  (b)  to 
diminish  the  amount  of  suppuration,  and  so  the  risk  of  necrosis  after 
the  interference  with  the  periosteum  which  is  entailed  by  the  operation. 

The  limb  being  rendered  evascular  by  vertical  elevation  as  the  pa- 
tient is  taking  the  anaesthetic,  and  the  application  of  Esmarch's  band- 
age, is  firmly  supported  on  sand  bags,  steel  probes  are  placed  in  the 
cloacae  which  mark  the  limit  of  the  disease,  and  with  a  strong-backed 
scalpel  the  surgeon  makes  an  incision  between  them  on  the  inner  sur- 
face of  the  tibia  down  to  the  bone.  If  only  one  sinus  is  present,  this 
will  probably  be  taken  as  the  centre  of  the  incision.  The  soft  parts 
being  reflected,  with  every  care  of  the  periosteum,  partly  with  the 
finger,  partly  with  a  blunt  dissector,  the  new  sheath  of  bone,  spongj' 
and  vascular,  is  thoroughly  exposed  with  a  chisel  and  mallet.     This 

*  Freedom  from  syphilis  and  phthisis  will  be  noted. 

f  It  is  supposed  here  that  the  sequestrum  is  one  of  considerable  size. 


SEQUESTEOTOMY.  933 

is  then  cut  into  and  sufficiently  removed  so  as  to  expose  its  cavity 
completely  from  end  to  end*  The  sequestrum  is  now  removed  with 
sequestrum-forceps,  or  prised  out  with  an  elevator.  If  too  large,  it 
must  be  divided  with  cutting-forceps.  The  bed  of  ill-formed  granula- 
tion-tissue in  which  the  sequestrum  lay  is  then  carefully  examined 
for  any  small  bit  which  may  be  concealed,  and  this  tissue  is  all  scraped 
away  with  a  sharp  spoon.  When  the  surgeon  is  satisfied  that  all  the 
mischief  has  been  removed,  he  plugs  the  resulting  cavity  carefully 
with  strips  of  dry  gauze,  dusted  with  iodoform,  bandages  these  dress- 
ings firmly  on  while  the  limb  is  elevated,  and  not  till  then  removes  the 
Esmarch's  bandage.  If  the  bandage  is  removed  before  the  dressings 
are  applied,  such  free  venous  oozing  takes  place  that  the  plugs  are  at 
once  loosened  and  rendered  inefficient,  and  the  wound  has  to  be  re- 
dressed shortly.  The  limb  is  kept  raised  on  a  back  splint  and  an  in- 
jection of  morphia  given. 

Two  questions  with  regard  to  sequestrotomy  require  to  be 
alluded  to — viz.,  that  of  performing  early  sub-periosteal  re-sec- 
tion— i.e.,  as  soon  as  the  bone  is  dead,  and  before  any  shell  of  new  bone 
has  formed  around  it,  and  that  of  amputation. 

Early  Sub-periosteal  Resection. — Mr.  Holmesf  has  discussed 
this  question,  and  given  the  following  advantages  and  disadvantages: 
"The  advantages  of  sub-periosteal  resection  of  the  shaft  of  the  bone 
over  the  expectant  treatment  are:  (1)  That  it  takes  away  what  is  a 
source  of  very  acute  and  dangerous  constitutional  irritation,  and  (2) 
that  it  avoids  the  embarrassment  of  future  operations,  and  the  tedious- 
ness  of  the  convalescence  Avhich  follows  on  the  invagination  of  a  large 
sequestrum.  The  drawbacks  are  chiefly  two :  the  almost  certainty  of 
more  or  less  shortening,  and  the  great  probability  of  abscess  spreading 
into  the  nearest  joint." 

Antiseptic  treatment  will  probably  remove  this  second  drawback — 
i.e.,  after  the  operation  there  will  be  no  acute  suppuration  to  make  its 
way  into  a  joint.  The  certainty  of  shortening  which  takes  place  here, 
although  the  fibula  is  present  to  act  as  a  stay,  and  to  prevent  any  ap- 
proximation of  the  ankle  to  the  knee,  is  a  much  more  serious  draw- 
back, and  when  coupled  with  the  fact  that  the  patients  who  would  be 
submitted  to  early  sub-periosteal  resection  are  often  only  just  recovered 
from  a  very  prostrating  illness  seems  to  me  to  be  strongly  against  it. 

*  Mr.  Howse  (Brit.  Med.  Journ.,  1874,  vol.  i.  p.  475)  lavs  great  stress  on  the  need  of 
this.  The  new  bone  slionld  be  removed  as  far  as  a  probe  can  be  passed  upwards  or 
downwards  inside  it,  so  as  to  make  the  whole  easily  granulate  up  from  the  bottom. 
Otherwise,  the  part  that  is  not  laid  open  will  very  likely  persist  witii  a  sinus.  Further- 
more, laying  the  whf>le  cavity  open  not  only  ensures  its  granulating  np  from  the  bottom, 
but  also  allows  of  the  removal  of  all  ill-formed  granulation  material. 

t  Surgical  Treatment  of  Children's  Diseases,  p.  386. 


934  OPERATIONS   OX    THE   LOWER   EXTREMITY. 

Question  of  Amputation. — The  following  are  some  of  the  condi- 
tions wliieh  will  call  for  tliis  operation  :  (1)  When  the  patient's  vitality 
is  so  low  as  to  be  unable  to  repair  the  wound  of  an  early  sub-periosteal 
resection,  or  to  stand  the  tax  upon  it  of  the  expectant  treatment;  (2) 
When  the  epiphyses  are  perforated,  and  the  knee  or  ankle  (especially 
if  both  are  affected)  are  involved;  (3)  If  a  condition  of  chronic  sep- 
ticaemia is  present;  (4)  If  the  general  health,  from  the  presence  of 
phthisis,  lardaceous  disease,  or  syphilis,  is  much  impaired. 

TREATMENT  OF  COMPOUND  FRACTURES.* 

The  following  special  points  for  consideration  arise  here — viz., 
(1)  The  reduction  of  protruding  fragments  and  the  treatment  of 
splinters;  (2)  The  best  mode  of  dressing  the  wound ;  (3)  Complica- 
tions ;  (4)  The  question  of  amputation. 

(i.)  Protrusion  of  Fragments. — It  is  usually  the  upper  one  which  pro- 
trudes. The  difficulty  of  reduction  is  in  proportion  to  the  size  of  the 
wound,  the  length  of  the  protruding  bone,  and  the  amount  of  spasm. 
If  reduction  cannot  be  effected  by  moderate  extension  and  dexterous 
manoeuvring,  the  wound  must  be  enlarged,  and  if  this  is  not  sufficient, 
part  of  the  bone  must  be  removed  with  a  narrow-bladed  saw  (Adams' 
osteotomy  saw  will  be  found  very  useful),  care  being  taken  to  separate 
the  periosteum  first,  and  to  protect  the  soft  parts  with  a  blunt  dissector 
passed  under  the  bone  and  by  retractors.  If  the  bone  is  splintered, 
some  judgment  is  required  as  to  what  pieces  to  remove.  Those  which 
are  still  adherent  by  their  periosteum  should  be  left.  Those  completely 
torn  away  must  be  removed,  whether  they  carry  their  periosteum  or 
not.  As  to  a  third  set  paitly  adherent,  partly  not,  these,  as  a  rule, 
partially  die  in  proportion  to  the  injury  to  tlieir  periosteum,  and  keej) 
up  for  a  long  time  irritation,  and  delayed  union  with,  perhaps,  sup- 
puration, erysipelas,  etc.  They  must,  therefore,  as  far  as  practicable, 
be  removed,  counter-openings  being  made  for  the  purpose,  when  they 
cannot  be  reached  through  the  wound. 

(ii.)  In  dressing  the  wound  the  one  great  object  is  to  convert  the  fracture 
as  soon  as  possible  into  a  simple  one.  In  less  severe  cases,  sealing  a 
small  clean  cut  "wound  at  once  with  dry  gauze,  and  collodion  and  iodo- 
form, or  tinct.  benz.  co.,  will  be  sufficient.  But  in  those  cases,  common 
enough  in  large  hospital  practice,  where  the  wound  is  extensive  and 
lacerated,  and  accompanied  by  much  contusion  of  the  soft  parts,  with 
abundant  blood  extravasation,  wdth  much  comminution  of  fragments 
and  injury  to  the  periosteum,  or  where  the  fracture  is  complicated  with 

*  From  the  frequency  with  which  these  occur  in  the  leg  this  subject  will  be  treated 
here.  The  account  is  taken  largely  from  the  article  "Fractures,"  Syst.  of  Surg.,  vol.  i, 
p.  421,  which  I  rewrote  in  1882. 


TREATMENT    OF   COMPOUND    FRACTURES.  935 

a  dislocation,  the  antiseptic  method  will  be  found  to  give  the  best  re- 
sults in  the  largest  number  of  cases. 

While  an  ana?sthetic  is  given,  the  limb  is  cleansed  with  lint,  and  1 
in  40  carbolic  lotion.  An  Esmarch's  bandage  being  applied,  and  the 
wound  enlarged,  the  bone  which  requires  it  (vide  supra)  is  removed, 
any  vessels  secured,*  and  a  1  in  30  solution  of  carbolic  acid  is  injected 
into  all  the  recesses  of  the  wound  by  means  of  a  syringe  with  a  gum- 
elastic  catheter  attached  by  tubing.  Prof.  Lister  has  shown  that  this 
must  not  be  done  too  vigorously,  as  extensive  injection  of  the  cellular 
interspaces  may  set  uj)  serious  irritation  and  sloughing.  For  this  rea- 
son he  advises  that  the  outlet  of  the  wound  should  not  be  held  closed 
around  the  catheter,  but  left  freely  open  daring  the  syringing.  If  the 
spray  or  irrigation  with  mercury  perchloride  and  gl3'cerine  are  em- 
ployed, and  one  or  other  should  always  be  made  use  of,  I  would 
strongly  advise  slitting  up  any  very  undermined  parts,  and  making 
free  counter-openings  for  drainage.  All  haemorrhage  being  arrested, 
and  any  torn  nerves  pared  and  sutured,  the  recesses  of  the  wound  are 
dried  with  sponges  in  holders,  powdered  iodoform  f  with  boracic  acid 
are  then  dusted  in,  and  dressings  of  dry  sal-alembroth  or  iodoform 
gauze,  and  the  limb  put  up  either  in  a  back  and  two  side  splints,  or, 
according  to  Mr.  Croft's  directions,  in  plaster-of-Paris.  Of  the  two  I 
prefer  the  former  in  severe  cases  for  the  first  week ;  infrequent  dress- 
ings, wherever  practicable,  are  most  essential. 


*  See  tlie  case  at  p.  925. 

t  Tliis  most  valuable  drug  is  not  sufficiently  used  in  these  cases.  I  may  briefly 
mention  three  cases  in  which  limbs  were,  I  think,  saved  by  it.  One  was  a  very  severe 
coraponnd  fracture  of  the  femur  in  a  man,  aged  forty-six,  who  fell  twenty-two  feet  on 
to  the  bank  of  the  Than)es,  striking  a  stone  buttress  as  he  went  down.  I  saw  him  about 
an  hour  after  the  accident.  The  fragments  wereuinch  displaced  and  overlapping,  the 
lower  one  being  also  split  vertically,  but  not  as  far  as  the  knee-joint.  The  ends  of  both 
were  bare,  and  the  vastus  externus  and  hamstrings  were  lacerated,  the  injury  having 
been  made  greater  by  the  patient  having  been  lifted  ofT  the  mud  on  to  which  he  fell 
into  a  boat,  and  then  into  a  cab.  Ether  having  been  given,  the  external  wound,  through 
which  the  vastus  externus  protruded,  was  freely  enlarged,  and  its  recesses  well  washed 
out  with  1  in  30  carbolic-acid  solution,  as  advised  above.  About  3j  of  iodoform  was 
then  carried  down  rigiit  between  the  fragments  by  means  of  the  finger  and  a  narrow 
spatula,  and  two  large  drainage-tubes  inserted.  An  aseptic  result  was  secured  from 
the  first  and  maintained  throughout  by  the  dresser  (Mr.  J.  H.  Lister),  the  man  making 
an  excellent  recovery.  The  second  case  was  that  of  a  compound  comminuted  fracture 
of  the  leg,  with  wound  of  the  anterior  tibial  artery  (mentioned  at  p  925).  The  third 
occurred  in  a  boy  with  compound  separation  of  the  lower  epiphysis  of  the  tibia,  in 
which  two  inches  of  the  protruding  diaphysis  were  removed.  The  case  did  so  well 
after  the  introduction  of  iodoform  and  the  other  precautions  already  given,  that  the 
first  dressings  (dry  sal-alembroth  gauze)  were  not  removed  till  the  eiglitli  day,  and  the 
lad  recovered  with  an  excellent  limb. 


936  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

(iii.)  Complications. — My  space  will  only  allow,  me  to  enumerate  these. 
They  are  local  and  general.  The  former  include  pruritus,  vesicles, 
ecchymosis,  suppuration,  oedema,  phlebitis,  gangrene,  ostitis,  caries, 
necrosis,  muscular  spasms,  dislocations,  and  implication  of  a  neigh- 
boring joint.  The  general  complications  are  such  as  are  common  to 
all  injuries — viz.,  traumatic  fever,  delirium,  erysipelas,  septicaemia, 
pyaemia,  hectic,  tetanus,  jaundice,  and  retention  of  urine;  in  older 
patients  a  tendency  to  hypostatic  congestion  and  broncho-pneumonia, 
and  finally,  in  a  few  cases,  pulmonary  fat-embolism. 

(i'v.)  Quedions  of  Amputntion. — The  following  are  amongst  the  condi- 
tions requiring  primary  amputation  :  (1)  When  a  limb  is  torn  off  by  a 
cannon  ball,  a  portion  of  shell,  or  by  machinery.  (2)  When  the  division 
of  the  soft  parts  is  nearly  complete,  except  in  the  case  of  a  clean  cut 
across  the  phalanges,  metacari^us,  or  metatarsus;  even  the  forearm 
may  occasionally  be  saved  under  similar  circumstances.  (3)  When 
there  is  much  actual  loss  of  s.oft  parts,  as  when  one  side  of  a  limb  is 
torn  away,  or  the  skin  is  extensively  peeled  off.  (4)  When,  with  or 
without  great  comminution  of  the  bones,  there  is  much  bruising  and 
laceration  of  the  soft  parts,  with  protrusion  of  muscular  bellies,  and 
extensive  tearing  up  of  deep  planes  of  areolar  tissue.  (5)  In  some 
cases  when  the  principal  artery  and  nerves  of  the  limb  are  both 
divided  ;  thus,  in  the  case  of  the  lower  limb,  primary  amputation  will 
usually  be  required.  (6)  In  certain  cases  of  severe  haemorrhage,  pri- 
mary^  or  secondary.  On  this  subject  I  must  refer  m}'  readers  to  the 
remarks  already  made  at  p.  924.  (7)  Some  cases  of  compound  frac- 
ture of  large  joints — viz.,  when  one  bone  is  shattered  or  more  than  one 
is  broken  :  when  there  is  much  laceration  of  the  ligaments ;  when,  in 
addition  to  comminution  of  the  bones,  there  is  much  contusion  of  the 
soft  parts,  especially  if  complicated  with  division  of  an  artery  ;  when 
the  foreign  body  which  has  caused  the  fracture  remains  in  the  joint, 
or,  projecting  into  it  from  its  bed  in  the  bone,  cannot  easily  be  removed, 
or  when  there  is  much  damage  to  the  articular  surfaces.  It  will  be 
understood  that  all  these  forms  of  injury  are  most  ftital  when  affecting 
the  knee  or  hip ;  in  dealing  with  other  joints  much  greater  latitude 
may  be  allowed. 

Finally,  before  deciding  on  amputation,  the  surgeon  must  take  into 
consideration,  in  addition  to  the  above  points  which  concern  the  frac- 
ture itself,  any  general  information  to  be  gained  about  the  patient 
himself.  Thus,  the  age,  constitution,  habits,  any  sign  of  visceral 
disease,  and  the  appearance  of  the  patient,  are  all  points  of  material 
importance  in  coming  to  a  decision  between  amputation  and  an  attempt 
to  save  the  limb.  Thus,  to  make  my  meaning  clearer,  there  are  no 
more  anxious  cases  than  severe  compound  fractures  in  dwellers  in 


TREATMENT  OF  COMPOUND  FRACTURES.  937 

large  towns,  who  are  past  middle  life,  flabbily  fat,  with  dilated  venules 
about  the  cheeks  and  nose,  whose  conjunctivae  are  slightly  jaundiced, 
the  urine  of  low  specific  gravity  and  perhaps  albuminous.*  The  sur- 
geon must  here  bear  in  mind  that  saving  the  patient's  life  is,  after  all, 
of  more  importance  than  the  preservation  of  his  limb. 

In  performnig  amputation  in  these  cases  of  compound  fracture  it  is 
always  to  be  remembered  that  the  injury  is  not  so  localized  as  would 
appear  from  the  surface;  thus,  in  compound  fracture  of  the  leg  there 
is  often  extensive  loosening  of  the  skin  from  the  deep  fascia,  and 
extravasation  of  blood  into  the  deep  planes  of  connective  tissue  for 
some  distance  above,  the  knee  joint  being  perhaps  full  of  blood,  and 
its  cartilages  bruised.  In  such  cases  if  amputation  be  performed  just 
above  the  injury,  sloughing  and  separation  of  the  flaps  will  inevitably 
follow.  On  the  other  hand,  in  cases  of  severe  compound  fracture  of 
the  thigh,  where  amputation  is  required  high  up,  it  will  be  found 
better  practice  to  amputate,  in  part  at  least,  through  injured  tissues.f 

If,  in  addition  to  the  fracture,  there  are  serious  injuries  to  other 
organs,  immediate  amputation  is  useless  or  injurious.  The  only 
chance  of  recovery  here  is  afibrded  by  secondary  amputation,  after  the 
early  dangers  are  past. 

Secondary  amputation  may  be  required  for  profuse  suppuration 
with  hectic,  for  gangrene,  or  uncontrollable  haemorrhage.  The  decision 
must  here  be  made  according  to  the  needs  of  each  case.  The  surgeon 
must,  if  possible,  wait  till  the  traumatic  fever  and  constitutional  dis- 
turbance are  subsiding,  till  the  temperature  has  begun  to  fall,  and  till 
all  redness,  erysipelas,  and  sloughing  have  ceased.  On  the  other  hand, 
if  the  operation  be  deferred  till  the  powers  of  the  patient  are  running 
down  from  profuse  suppuration  and  hectic,  and  till  confirmed  asthenia 
has  set  in,  the  period  of  performing  it  will,  very  probably,  have  passed 
away. 

At  a  still  later  period  the  operation  may  be  desired  by  the  patient 
if,  in  consequence  of  non-union,  incurable  deformity,  or  tedious  bone 
disease,  the  limb  has  become  an  incumbrance  to  iiim.  Some  of  tliese 
conditions  may,  of  course,  be  treated  by  resection,  osteotomy,  etc. 


*  Note  will  also  be  taken  of  the  occupation,  as  in  brewers,  draymen,  and  commer- 
cial travellers. 

t  Thus,  in  the  case  of  a  young  railway  porter,  whose  thigh  was  smashed  by  a  railway 
accident  at  Epsom,  I  performed  amputation  at  the  level  of  the  lesser  trochanter,  in 
preference  to  the  hip-joint.  The  damaged  flaps  sloughed,  as  I  expected,  but  the 
patient  made  a  good  recovery,  after  the  removal  of  some  dead  bone.  The  precautions 
already  given  against  shock  (p.  848)  will,  of  course,  be  taken  in  these  cases. 


938  OPERATIONS   ON   THE   LOWER   EXTREMITY. 

CHAPTER  VI. 

OPERATIONS  ON  THE  FOOT. 

LIGATURE  OF  THE  DORSALIS  PEDIS.— SYME'S  AM- 
PUTATION—ROUX'S  AMPUTATION. -PIROGOFF'S 
AMPUTATION.  —  SUB-ASTRAGALOID  AMPUTA- 
TION.-EXCISION  OF  THE  ANKLE.-EXCISION  OF 
BONES  AND  JOINTS  OF  THE  TARSUS.— EXCIS- 
ION OF  ASTRAGALUS.— EXCISION  OF  OS  CALCIS. 
—MORE  COMPLETE  TARSECTOMY  FOR  CARIES.— 
REMOVAL  OF  WEDGE  OF  BONE  FOR  TALIPES. 
— CHOPART'S  AMPUTATION.  —  AMPUTATION  AT 
METATARSO  -  PHALANGEAL  JOINT.  —  AMPUTA- 
TION OF  THE  TOES. 

LIGATURE  OF  THE  DORSALIS  PEDIS  (Fig.  181). 

Indications. — Very  rare.  (1)  Wounds.  (2)  Together  with  the 
posterior  tibial  in  the  lower  third,  for  hemorrhage  from  punctured 
wounds  of  the  sole  resisting  other  treatment.  (3)  For  some  vascular 
tumors  of  the  foot. 

Line. — From  the  centre  of  the  ankle-joint  to  the  upper  part  of  the 
first  interosseous  space. 

Guide. — The  above  line  and  the  adjacent  tendons  of  the  great  and 
second  toe. 

Relations  : 

In  Front. 

Skin,  fascia? ;  branches  of  saphense  veins,  and  of 
musculo-cutaneous  and  anterior  tibial  nerves. 

A  special  deep  fascia  continuous  with  the  sheaths 
of  the  adjacent  tendons. 

Extensor  brevis  (innermost  tendon). 

Outside.  Inside. 

Vein.  Vein. 

Anterior  tibial  nerve.  Extensor  longus  pollicis. 

Extensor  longus  digitorum. 

Dorsalis  pedis  artery. 

Behind. 

Astragalus;  scaphoid;  internal  cuneiform. 

Operation  (Fig.  181). — The  foot  being  cleansed,  an  incision  about 
Ij  inch  long  is  made  in  the  line  of  the  artery,  in  the  lower  part  of  its 


syme's  amputation. 


939 


course,  commencing  about  1'}  inch  below  the  ankle-joint.  Skin  and 
fasciae  being  cut  through,  and  any  superficial  veins  tied  with  chromic 
gut  or  drawn  aside,  one  of  the  long  extensors  is  found  (its  sheath  is 
not  to  be  opened),  and  the  strong  fascia  given  off  from  them  opened. 
If  the  extensor  brevis  cross  the  artery  at  this  spot  it  must  be  drawn 
aside.     The  ligature  should  be  passed  from  without  inwards. 

SYME'S  AMPUTATION  (Figs.  182,  185,  189). 

An  amputation  at  the  ankle-joint  by  a  heel-flap,  with  removal  of 
the  malleoli. 

Operation. — Ha?morrhage  being  controlled,  any  sinuses  present 
scraped  out,  the  foot  bandaged,*  and  held  at  right  angles  to  the  leg, 

Fig.  181. 


Fig   182. 


The  dorsalis  pedis  (too  much 
of  the  artery  is  shown  clean)  is 
seen  lying  between  the  extensor 
longus  pollicis  and  digitorum, 
and  crossed  by  the  innermost 
tendon  of  the  short  extensor. 


The  parts  in  a  Syme's  am- 
putation before  the  heel-flap 
Is  adjusted  (left  side).  The 
bones  are  shown  above  with 
the  extensor  tendons  and  the 
anterior  tibial  vessels,  and, 
below-,  the  tendo-Achillis.  On 
the  inner  side  the  flexor  ten- 
dons and  the  plantar  arteries 
are  shown  cut ;  on  the  outer 
side,  the  peron«i.  This  Fig. 
should  be  contrasted  with  Fig. 
187. 


the  surgeon,  standing  a  little  to  the  right,  but  so  as  easily  to  face  the 
sole,  makes,  with  a  short,  strong  knife,  an  incision  (in  the  case  of  the 
left  foot)  from  the  tip  of  the  external  malleolus  to  a  point  ^  inch 

*  So  as  to  give  a  grip,  and  also  to  prevent  the  assistant's   hands  from   being  septic 
when  he  holds  the  stump  a  little  later. 


940  OPERATIONS   ON   THE    LOWER    EXTREMITY. 

below*  the  internal  one,  this  incision  not  going  straight  across  the 
sole  as  in  Pirogoff' s  amputation,  but  pointing  a  little  backwards  to- 
wards the  heel.f  The  horns  of  this  incision  are  then  joined  by  one 
passing  straight  across  the  joint,J  and  severing  everything  at  once 
down  to  the  ankle-joint.  The  foot  being  now  strongly  bent  down- 
wards, the  lateral  ligaments  are  severed,  and  the  joint  thus  fully 
opened.  The  foot  being  slightly  twisted  from  side  to  side,  the  soft 
parts  on  either  side  are  carefully  divided,  especial  precautions  being 
taken  on  the  inner  side  to  cut  the  posterior  tibial  artery  as  long  as 
possible  (to  ensure  getting  below  the  internal  calcanean)  and  not 
to  prick  it  afterwards. 

The  foot  being  still  more  depressed,  the  upper  non-articular  surface 
of  the  OS  calcis  comes  into  reach,  and  then  the  tendo-Achillis.  This 
is  severed,  and  the  heel-flap  next  dissected  off  the  os  calcis  from  above 
downwards,  especial  care  being  taken  to  cut  this  flap  as  thick  as  pos- 
sible, not  to  score  or  puncture  it,  but  rather  to  peel  it  off  the  bone  with 
the  left  thumb-nail  kept  in  front  of  the  knife,  aided  by  touches  of 
this.§ 

The  foot  having  been  removed,  the  soft  parts  are  carefully  cleared  off 
the  malleoli,  and  a  slice  of  the  tibia  sufficiently  thick  to  include  these 
prominences  removed.  The  slice  should  in  any  case,  to  avoid  shorten- 
ing, be  the  thinnest  possible.  Prof.  Macleod||  has  recommended  to 
remove  only  the  malleoli,  leaving  the  cartilage  on  the  under  surface 
of  the  tibia.  I  have  followed  his  advice  in  my  last  two  cases — one  a 
private  patient  of  sixty -three ;  here  I  had  not  the  carrying  out  of  the 
after-treatment,  and  the  cartilage  exfoliated.  The  other  was  a  much 
younger  patient,  who,  in  addition  to  the  disease  of  the  tarsus,  had 
active  secondary  syphilis ;  in  spite  of  pulpy  sinuses  which  required 


*  The  directions  usually  given  are  to  go  behind  this  point  as  well  as  below  it,  but 
by  following  the  above  course  the  posterior  tibial  is  more  likely  to  escape  section  be- 
fore its  time,  and  the  flap  will  be  found  sufBciently  symmetrical. 

f  If  the  foot  is  small,  and  still  more  if  the  parts  on  the  dorsum  are  damaged,  the 
plantar  incision  should  run  straight  across.  On  the  other  hand,  the  more  prominent 
the  heel,  the  more  should  the  flap  point  backwards.  This  will  facilitate  turning  the 
flap  over  the  heel. 

X  Or  with  a  very  slight  convexity.  If  anything  of  a  flap  is  made  here,  the  operator 
is  liable  to  get  away  from  the  joint  and  cut  into  the  neck  of  the  astragalus.  Moreover, 
the  parts  are  not  well  nourished,  especially  if  sinus-riddled  or  undermined, 

^  If,  in  a  young  subject,  the  epiphysis  comes  away  in  the  heel-flap,  it  may  remain 
there  if  the  parts  are  healthy.  The  same  course  may  be  followed  with  the  periosteum, 
if  it  is  found  loose  and  peels  easily  away.  Mr.  Johnson  Smitb,  when  amputating  both 
feet  for  frost-bite,  left  the  periosteum  on  one  side.  On  the  other  no  attempt  was  made 
to  save  it.  The  first  stump  was  much  larger  than  the  other,  harder,  and  more  rounded  ; 
more  like  that  of  a  Pirogoff's  amputation. 

1!  BriL  Med.  Journ.,  1869,  vol.  ii.  p.  239. 


syme's  amputation. 


941 


repeated  scraping  out  (Fig.  185),  no  exfoliation  took  place.  If  the 
stump  can  be  kept  aseptic,  Prof.  Macleod's  advice  seems  to  me  well 
worth  a  further  trial,  as  it  entails  less  shortening  of  the  limb  and  does 
away  with  the  risk  of  septic  phlebitis,  which  may  be  brought  about 
by  opening  the  cancellous  tissue.  If,  on  the  other  hand,  the  lower 
end  of  the  tibia  is  d-'seased,  it  must  be  removed  and  the  sawn  surface 
gouged  or  treated  with  a  sharj)  spoon.     If  the  cartilage  is  only  slightly 

Fig.  183. 


Koux's  amputation  at  the  ankle-joint  by  an  internal  flap.    Below  is  shown  a  foot 
upon  which  the  operation  has  been  performed.    (Smith  and  Walsham.) 

diseased,  it  may  be  sliced  off  with  the  knife,  and  here  and  there 
treated  with  a  gouge. 

Tendons  are  now  cut  short,  sinuses  laid  open  or  thoroughly  scraped 
out,  and  the  vessels  secured.  Free  oozing  is  often  present  in  chronic 
pulpy  cases,  or  where  the  periosteum  has  been  left  in  the  heel-flap. 
It  is  best  treated  by  firm  pressure  with  dry  dressings,  and  elevation 
of  the  stump.  Drainage  being  provided,  the  sutures  are  inserted ; 
where  many  sinuses  have  been  present  along*  the  line  of  the  incision, 
it  is  no  good  uniting  the  wound  too  closel3^ 

*  Sinuses  which  have  been  scraped  out  will  give  good  drainage  if  enlarged  If  any 
puncture  has  been  made  in  the  heel-flap,  it  should  be  utilized  for  the  same  purpose. 


942  OPERATIONS    ON   THE   LOWER    EXTREMITY. 

Roux's  Modification  of  Syme's  Amputation.— In  cases 
where  a  satisfactory  heel-flap  cannot  be  obtained,  an  efficient  substi- 
tute can  be  got  by  a  large  internal  flap. 

The  incision  is  commenced  at  the  apex  of  the  outer  malleolus  and 
carried  half  across  the  front  of  the  ankle-joint,  from  whence  it  should 
run  inwards  in  an  oblique  direction  over  the  astragalo  scaphoid 
joint,  then  pass,  in  a  curved  manner,  downwards  and  backwards  to 
the  middle  line  of  the  sole  of  the  foot,  and,  running  along  the  under 
surface  of  the  heel,  must  ascend  the  posterior  aspect  of  that  part,  and 

Fig.  184. 


Roux's  amputation.    The  incisions  shown  from  the  outer  and  the  inner  side. 
(Stimson.) 

terminate  at  the  outer  malleolus,  where  it  commenced.  The  ankle- 
joint  should  be  opened  at  its  upper  and  outer  part,  the  calcis  dissected 
from  its  connections,  the  malleoli  and  a  slice  from  the  articular  sur- 
face of  the  tibia  removed,  and  the  operation  will  be  complete.  The 
shape  of  the  flap  will  be  gathered  from  the  appearance  of  a  foot 
operated  upon  TFig.  1S3). 

Causes  of  Failure  after  Symes  Amputation.— (1)  Sloughing 
of  the  heel-flap.  This  is  nearly  always  due  to  faulty  operating,  to 
scoring  or  "  button-holing  "  the  flap,  or  to  dividing  the  posterior  tibial 
high  up.* 

(2)  Persistence  of  sinuses  and  pulpy  disease.  If,  in  spite  of  repeated 
scraping  out  (Fig.  185)  with  the  aid  of  anaesthetics,  this  condition 

Where  a  diseased  foot  has  been  long  on  a  back  splint,  tlieskin  over  the  tendo-Achiilis 
may  be  so  thinned  that  it  is  advisable  to  make  a  counter-puncture  here  and  insert  a 
tube. 

*  If  possible,  the  cut  ends  of  the  two  plantar  arteries  should  always  be  seen,  and 
not  the  single  month  of  the  posterior  tibial.  In  the  former  case  the  surgeon  is  certain 
that  the  main  vessel  is  divided  below  the  internal  calcanean  branch. 


PIROGOrF  S   AMPUTATION. 


943 


recurs  inveterately  and  spreads  along  the  sheaths,  the  limb  must  be 
amputated  higher  up.  This  will,  however,  be  rarely  called  for  with 
perseverance  on  the  part  of  the  patient  and  surgeon,  and  a  determi- 
nation on  the  part  of  the  latter  to  treat  this  condition  as  a  kind  of 
malignant  disease.  If  one  or  two  sinuses  remain,  and  look  likely  to 
persist,  scraping  out  should  be  resorted  to  at  once. 
(3)  Recurrence  of  caries  in  the  tibia. 

PIROGOFF'S  AMPUTATION  (Figs.  186,  187,  188,  189). 

An  amputation  at  the  ankle-joint,  in  which  the  posterior  jDart  of  the 
OS  calcis  is  retained  and  united  to  the  sawn  surface  of  the  tibia. 

Question  of  the  Value  of  this  Operation  especially  as  com- 
pared with  Syme's    Amputation. — Disadvantages:   These   have 


Fig.  185. 


Fig.  186. 


Fig.  185.— a  Syme's  stump  soundly  healed  after  scraping  out  of  sinuses  had  been  resorted  to. 
The  patient  was  sent  to  me  by  Dr.  Fraser,  of  Romford,  and  had  active  secondary  syphilis  as 
well  as  extensive  caries  of  the  tarsus. 


been  put  prominently  forward  by  Scotch  surgeons.  1.  The  amputa- 
tion is  not  suited  for  cases  of  disease,  except  of  distinctly  traumatic 
origin  in  young  healthy  subjects.  2.  Occasionally  the  sawn  os  calcis 
fails  to  unite,  causing  either  a  kind  of  movable  joint  or  necrosis.  3. 
It  is  said  by  some  that  the  stump  is  more  difficult  to  fit  with  an  arti- 
ficial foot.*  The  first  two  objections  are  undoubted,  but  I  think  that 
they  are  quite  outweighed  by  the  Advantages  :  1.  No  dissection  of  the 

*  Prof.  Macleod  thinks  that  the  presence  of  the  heel  is  here  "  a  great  drawback,  and* 
that  the  back  of  the  heel,  not  the  firm  plantar  pad,  is  what  comes  in  contact  witli  the 
ground." 


944 


OPERATIONS    ON    THE    LOWER    EXTREMITY. 


heel-flap  is  needed.  2.  The  blood-supply  is  less  interfered  with.  3. 
The  stump  is  firmer  and  more  solid.  4.  The  stump  is  longer  by  1  or 
H  inch,  often  more.*  5.  The  stump  does  not  go  on  wasting,  as  is  the 
case  after  a  Syme's  amputation.f  6.  Dr.  Hewson  (Amer.  Journ.  Med. 
Sci.,  1864,  pp.  121, 129)  has  pointed  out  that,  in  a  Pirogoff",  the  origin 
and  insertion  of  the  gastrocnemius  being  both  intact,  the  combined 
movements  of  the  knee  and  ankle  are  preserved,  as  in  running,  etc. 

Operation. — The  position  of  the  patient's  foot  and  tlie  surgeon 
being  as  at  p.  939,  an  incision  is  made,  straight  across  the  sole,  from 
the  tip  of  the  external  malleolus  to  a  point  i  inch  below  the  internal 
one. J  This  incision  goes  right  down  to  the  bone.  Its  horns  are  then 
joined  by  a  transverse  cut  across  the  front  of  the  ankle.  The  lateral 
ligaments  are  now  severed,  care  being  taken  to  cut  inside  the  malleoli 
and  to  divide  the  posterior  tibial  artery  as  long  as  possible — i.e.,  below 


Fig.  187. 


Fig.  18S. 


Fig.  188.— PirogofTs  amputation  as  modifiecl  by  Dr.  E.  Watson.    (Smith  and  Walsham.) 


its  origin  into  the  two  plantar — and  not  to  prick  it  after  it  is  divided. 
With  a  few  touches  of  the  knife  at  either  side  of  the  astragalus,  aided 
by  twisting  of  the  foot  from  side  to  side  and  forcible  bending  of  it 
downwards,  the  non-articular  part  of  the  upper  surface  of  the  os  calcis 
comes  into  view  (Fig.  186).  A  groove  is  now  cut  through  the  fatty 
tissue  and  the  periosteum,  and  the  saw  applied  just  in  front  of  the 

*  Dr.  Hewson  (loc.  infra  cit.)  gives  the  shortening  after  a  PirogofF  as  from  1  to  2 
inches;  that  after  a  Syme  as  2}  to  3  inches. 

t  The  continuance  of  this  wasting  is  shown  by  the  hospital  patient  being  for  some 
time  obliged  to  stuff  the  socket  of  his  elephant-boot  with  a  sock.  It  is  not  intended 
by  this  to  depreciate  the  value  of  a  Syme's  stump.  Every  s.irgeon  knows  how  much 
good,  life-long  work  the  heel-flap  is  capable  of  however  much  it  shrinks,  as  long  as  it 
has  healed. 

X  I.e.,  not  pointing  backwards. 


pieogoff's  amputation.  945 

tenclo-Achillis,  obliquely  downwards  and  forwards,  care  being  taken 
to  bring  it  out  through  the  incision  in  the  heel.  The  foot  being 
removed,  the  soft  parts  around  the  bones  of  the  leg  are  carefully 
cleared  to  a  level  just  above  the  tibial  articular  surface  and  the 
malleoli.  The  saw  is  next  applied  in  the  reverse  direction  to  that 
just  given — viz.,  from  below  upwards  and  backwards,  and  slightly 
obliquely. 

The  vessels,  the  tibials,  anterior  peroneal,  and  perhaps  one  or  both 
malleolars,  having  been  secured,  the  tendons  cut  square,  the  bony  sur- 
faces are  placed  in  contact,  and,  if  needful,  drilled  with  a  clean  bradawl 
and  united  with  wire  or  stout  chromic  gut.* 

If  it  is  found  advisable  to  convert  the  Pirogoff  into  a  S^mie,  all  that 
is  needed  is  to  divide  the  tendo-Achillis  and  to  dissect  out  the  part  of 
the  OS  calcis,  keeping  the  knife  close  to  the  bone. 

Modifications  of  Pirogoff's  Amputation. — One  of  the  chief  of 
these  is  that  introduced  by  Dr.  E.  Watson  (Lancet,  1859,  vol.  i.  p. 
577).  He  claims — (1)  That  it  is  shorter  and  easier,  the  trouble  of 
disarticulation  being  avoided.  (2)  That  it  is  less  likely  to  damage 
the  posterior  tibial  artery.  (3)  That  it  does  away  with  one  of  the 
chief  difficulties  in  a  Pirogoff's  amputation  for  inj-ury — viz.,  the  want 
of  purchase  over  the.  smashed  parts  while  the  os  calcis  is  being  sawn 
through. 

Operation. — The  operator,  standing  as  before,  having  cut  across 
the  sole  from  the  tip  of  one  malleolus  to  the  corresponding  point  (p. 
939)  down  to  the  bone,  introduces  a  small  Butcher's  saw,  or  one  with 
a  narrow  blade,  into  this  wound,  and  saws  off  the  posterior  part  of  the 
OS  calcis  b}'  carrying  his  section  upwards  and  backwards.  This  and 
the  heel  being  now  retracted  by  an  assistant,  the  surgeon,  resuming 
his  knife,  cuts  upwards  behind  the  ankle-joint  between  the  saAvn 
bones.  The  ends  of  the  first  incision  are  now  joined  by  one  passing 
between  them,  the  skin  being  pulled  up  a  little  and  the  tendons  and 
vessels  severed  down  to  the  tibia  and  fibula  just  above  the  ankle-joint. 
Lastl}',  these  bones  are  sawn  through  in  a  slanting  manner  by  direct- 
ing the  saw  from  before  backwards  and  downwards.f  While  the  bones 
of  the  leg  are  being  sawn  the  heel-flap  should  be  held  well  up  against 
the  back  of  the  leg  to  keep  it  out  of  the  way. 


*  If  the  patient  is  young  and  healthy,  this  step  is  not  absohitely  needful.  I  would 
recommend  it  in  other  cases.  Thus  I  have  made  use  of  it  in  a  Pirogoff's  amputation 
for  inveterate  infantile  paralysis,  with  excellent  results.  If  wire  be  used,  it  must  be 
left  long.     A  little  ether  will  probably  be  needed  when  the  wire  is  removed. 

f  It  will  be  noticed  that  the  direction  of  the  bone  section  above  given  by  Mr.  Watson 
is  contrary  to  that  usually  taught. 

60 


946 


OPERATIONS    ON    THE    LOWER   EXTREMITY. 


SUB-ASTRAGALOID  AMPUTATION  (Fig.  189). 

This  amputation,  very  rarely  practiced  in  England,  has,  I  believe, 
largely  replaced  that  of  Chopart  in  France.  The  following  account  is 
taken  from  Dr.  Stimson  :* 

"  The  guides  to  this  operation  are  the  tip  of  the  external  malleolus 
and  the  head  of  the  astragalus.  The  joint  must  be  entered  from  in 
front  on  the  fibular  side,  and  the  strong  interosseous  ligament  which 
forms  the  key  to  the  articulation  must  be  divided,  step  by  step,  from 
before  backwards  and  inwards.  The  posterior  tibial  vessels  must  be 
carefully  avoided. 

"  Beginning  at  the  outer  side  of  the  heel  nearly  1  inch  below  the  tip 
of  the  external  malleolus,  an  incision  extending  through  to  the  bone 
is  carried  straight  forward  to  the  base  of  the  fifth  metatarsal  bone, 

Fig.  189. 


1.  The  incisions  in  Pirog(ift"s  ampiitation.  The  dotted  line  sliows  the  direction  of  the  plantar 
incision  in  that  of  Syme.  2.  The  incisions  in  sub-astragaloid  ;  and  3,  Those  in  Chopart's  ampu- 
tation. 

thence  curving  forwards  across  the  dorsum  of  the  foot  to  the  base  of 
the  first  metatarsal,  thence  obliquely  backwards  and  outwards  across 
the  sole  of  the  foot  and  around  its  outer  border,  rejoining  the  first 
horizontal  part  of  the  incision  at  the  calcaneo-cuboid  joint.  The  soft 
parts  must  be  separated  from  the  outer  surface  of  the  calcaneum  and 
cuboid  with  division  of  the  peroneal  tendons,  the  dorsal  flap  dissected 

*  Man.  of  Oper.  Surg.,  p.  113. 


EXCISION    OF   THE    ANKLE.  947 

back  to  tlie  head  of  the  astragalus,  and  on  the  inner  side  beyond  the 
tubercle  of  the  scaphoid,  thus  dividing  the  tendon  of  the  tibialis  anticus 
and  the  anterior  jiortion  of  the  internal  laternal  ligament.  The  inter- 
osseous ligament  can  then  be  easily  reached  by  depressing  the  toes, 
passing  the  knife  between  the  astragalus  and  scaphoid,  and  cutting 
backwards  and  inwards  along  the  under  surface  of  the  former.  The 
soft  parts  on  the  inner  side  are  then  separated  from  the  calcaneum, 
injury  to  the  vessels  being  avoided  by  keeping  close  to  the  bone 
between  it  and  the  tendons  of  the  flexor  communis,  the  foot  depressed, 
and  the  tendo-Achillis  divided.  This  last  is  a  very  difficult  part  of 
the  operation,  and  great  care  must  be  taken  to  keep  the  edge  of  the 
knife  close  to  the  bone  so  as  not  to  cut  through  the  skin.  The  poste- 
rior tibial  nerve  should  be  dissected  out  and  cut  off  as  high  as  possible, 
so  that  it  shall  not  be  pressed  upon  in  the  stump." 

EXCISION  OF  ANKLE. 

This  operation  is  one  of  very  disputed  value,  and  thus  rarely  per- 
formed. Objections:  (1)  Disease  here  is  often  associated  with  disease 
of  the  tarsus.  (2)  Even  if  the  wound  heals,  the  foot  left  is  often  of 
little  use.  (3)  Syme's  amputation  affords  not  only  a  radical  cure,  but 
a  most  excellent  stump.  This  may  be  imperilled  by  a  previous  exci- 
sion of  the  joint. 

Indications, — These,  which  are  very  few,  must  be  considered 
separately,  according  as  they  fall  under  the  head  of  A.  Disease,  B. 
Injury. 

A.  Disease. — (1)  The  patient  must  be  young  and  healthy,  with  no 
evidence  of  other  strumous  disease,  or  of  phthisis  or  syphilis.  (2)  The 
disease  should  be  of  traumatic  origin — e.g.,  following  a  sprain — and 
(3)  limited  to  the  bones  which  form  the  joint,  the  whole  astragalus 
being  taken  aw^ay  if  needful.  To  another  class  of  cases  in  which  this 
operation  has  been  too  often  performed — viz.,  where  the  patient's 
health  is  reduced  by  discharge,  pain,  hospital  air,  etc.,  where  other 
tarsal  bones  are  involved — this  excision  is  not  applicable;  it  is  here 
much  severer  than  amputation,  and  leaves  the  patient  most  liable  to 
recurrence.* 


*  In  Mr.  Holmes's  words  (Sy.tt.  of  ■^urg.,  vol.  iii.  p.  766),  in  the  first  class  of  cases 
"  the  inflammatory  softening  or  suppuration  does  not  usually  extend  far  from  the 
neighborhood  of  the  joint  originally  implicated,  and,  after  the  removal  of  the  diseased 
bone,  the  parts  take  on  a  healthy  action  and  become  rapidly  consolidated.  In  strumous 
disease,  on  the  other  hand,  inflammatory  softening,  if  not  diff'used  suppuration,  often 
exists  in  the  tarsal  bones  or  bones  of  the  leg  in  parts  not  exposed  to  view  in  the  opera- 
tion;  and,  in  patients  laboring  under  ger^eral  constitutional  affections,  the  parts 
operated  on,  instead  of  consolidating,  usually  soften,  and  after  a  long  and  exiiaustive 
suppuration  the  bones  are  found  carious,  leaving  no  resource  except  amputation,  and 
that  sometimes  under  unfavorable  circumstances." 


948  OPERATIONS   ON   THE    LOWER    EXTREMITY. 

The  chief  points  in  excision  of  the  ankle-joint  which  have  been 
raised  as  objections  to  the  operation  are:  (1)  Tlie  difliculty  of  free  ex- 
posure of  the  parts  to  be  dealt  with  ;  (2)  The  frequency  with  which 
other  bones  are  diseased.  Thus,  Mr.  F.  Jordan*  strongly  objected  to 
the  operation  on  the  ground  that  the  astragalus  is  not  a  long  bone 
with  an  epiphysis  in  which  the  chief  disease  may  lie,  but  a  short  bone 
consisting  of  a  mass  of  cancellous  tissue  throughout  which  the  disease 
is  more  or  less  diffused.  This  objection  may  be  answered  by  the  fact 
that  if  the  disease  in  the  astragalus  is  found  not  to  be  limited  to  the 
upper  articular  surface,  it  will  in  no  way  interfere  with  the  results  if 
the  whole  bone  is  removed. f  And  this  fact  will  meet  another  objection 
to  excision  of  the  astragalus  made  by  Prof.  Syme — viz.,  that  the  fre- 
quency with  which  disease  of  the  astragalus  originates  on  the  under 
surface  of  this  bone  (i.e.,  between  it  and  the  os  calcis;|:)  calls  rather  for 
amputation  than  excision.  (3)  The  difficulties  of  securing  afterwards 
a  splint  which  will  combine  the  three  following  essentials,  viz.,  (a) 
Sufficient  rest;  (b)  Sufficient  exposure  for  needful  change  of  dress- 
ings ;  (c)  The  possibility  of  antiseptic  treatment. 

B.  Injury. — In  a  young,  healthy  patient,  where  tbe'  vessels  and 
nerves  are  mainly  intact,  where  the  mischief  is  limited  to  the  ends  of  the 
bones,  an  attempt  to  save  the  limb  by  excision,  partial  or  complete,  is 
abundantly  justified.  The  steps  given  at  p.  984  for  the  antiseptic 
treatment  of  compound  fractures  should  be  carefully  attended  to,  as 
to  the  preservation  of  periosteum,  the  due  providing  of  drainage,  etc. 
As  to  gunshot  injuries.  Dr.  Otis§  thought  that  "  the  substitution  of 
excision  of  the  ankle-joint  for  amputation  eff'ected  no  saving  of  life," 
formal  excisions  being  rarely  successful. 

Operation, — This  may  be  either  by  two  lateral  incisions,  or  by  a 
transverse  one,  dividing  the  extensor  tendons,  which  are  sutured 
afterwards. 

Excision  by  Lateral  Incisions. — An  Esmarch's  bandage  being 
applied  above,  and  the  parts  rendered  evascular  as  well,  the  foot  is 

*  Lancet,  1867,  vol.  i.  p.  729. 

t  Mr.  Holmes,  whose  experience  of  this  operation  is  a  large  one,  advises  {Brit.  Med. 
Journ.,  1878,  vol.  ii.  p.  875)  that  the  whole  of  the  astragalus  should  always  be  removed, 
for  these  reasons — (1)  As  it  is  often  softened  to  a  considerable  depth,  mere  removal  of 
its  articular  surface  will  often  leave  disease  behind ;  (2)  in  patients  low  in  health,  or 
of  strumous  constitution,  the  violence  done  bv  the  saw  may  prove  the  starting-point 
of  renewed  caries ;  (3)  the  bones  of  the  leg  unite  quite  as  firmly  to  the  exposed  carti- 
laginous surfaces  of  the  os  calcis  and  scaphoid  as  they  do  to  the  sawn  surface  of  the 
astragalus;  (4)  the  shortening  is  not  appreciably  increased  ;  (5)  the  difficulty  of  the 
operation  is  lessened  (p.  949). 

t  Instances  of  extensive  removal  of  the  bones  of  the  tarsus  are  given  at  pp.  954, 
955,  956. 

§  Med.  and  Surg  Hist,  of  the  War  of  the  Rebellion,  pt.  iii.  p.  610, 


EXCISION    OF    THE    AXKLE.  949 

laid  upon  its  inner  side  firmly  supported  on  a  sand-bag.  An  incision 
is  made  along  the  lower  22  inches  of  the  posterior  border  of  the  fibula 
and  then,  when  it  has  reached  the  tip  of  the  malleolus,  it  is  carried 
downwards  and  forwards  at  an  angle  to  within  an  inch  of  the  base  of 
the  fifth  metatarsal  bone.  A  slight  flap  is  now  sufficiently  dissected 
forwards  to  expose  the  bone  and  to  clear  the  peronei;  these  being 
drawn  aside,  the  bone  is  divided  with  a  narrow  saw  or  cutting-forceps 
about  2  inches  above  the  malleolus,  and  removed  after  division  of  the 
external  lateral  ligament.  This  wound  is  now  covered  with  carbolized 
lint  and  the  foot  turned  over,  and  a  similar  angular  incision  made 
along  the  lower  2  inches  of  the  inner  margin  of  the  tibia,  and  then 
forwards  and  downwards  as  far  as  the  {)rojection  of  the  internal 
cuneiform  bone.*  A  flap  being  dissected  slightly  inwards,  the  tendons 
of  the  tibialis  and  flexors  are  exposed  and  retracted,t  the  knife  being 
kept  close  to  the  bone  so  as  to  avoid  the  posterior  tibial  vessels. 

The  internal  lateral  ligament  is  now  cut  through  close  to  the  tibia, 
and  on  displacing  the  foot  outwards  the  tibia  and  astragalus  present 
in  part  at  the  inner  wound.  A  metacarpal  saw  being  next  passed  from 
the  inner  to  the  outer  wound,  the  lower  end  of  the  tibia  is  sawn  ofl" 
sufficient! 3^  high  up  to  secure  a  healthy  section  of  bone  and  no  more. 
The  astragalus  is  next  treated  similarly,;}:  all  the  articular  cartilage 
being  removed.  Any  soft  patches  of  bone  are  next  gouged,  and  pulpy 
material  snipped  away  from  the  synovial  sheaths  of  the  tendons,  etc. 
All  sinuses  are  next  scraped  out  or  laid  open.  The  only  vessels  which 
will  require  tying  are  some  branches  of  the  peroneal  and  the  malle- 
olar, none  of  any  importance  being  divided.  Very  few,  if  any,  sutures 
should  be  used,  so  as  to  allow  of  very  free  drainage. 

Excision  by  Transverse  Incision. — The  parts  being  rendered 
evascular,  an  incision  is  made  transversely  across  the  front  of  the 
ankle-joint  from  the  tip  of  one  malleolus  to  the  other.  The  extensor 
tendons  being  divided,  the  anterior  and  lateral  ligaments  severed,  the 
end  of  the  tibia  is  exposed,  a  way  cleared  for  the  saw  just  above  the 
malleoli,  and  a  slice  removed.  The  upper  articular  surface  of  the 
astragalus  is  then  treated  in  the  same  way,  the  peroneal  and  flexor 

*  The  lower  extremities  of  these  incisions  need  not  go  down  to  the  bones. 

f  Unless  these  tendons  are  sufBciently  freed  from  tlieir  connection  with  the  lower 
end  of  the  tibia,  difficulty  will  be  met  in  everting  the  foot  sufficiently  to  bring  the  tibia 
out  of  the  wound  (Hancock,  Lancet,  1867,  vol.  i.  p.  731). 

X  If  tlie  disease  here  is  at  all  extensive,  this  bone  should  be  entirely  removed  (p. 
948).  If  a  seciion  only  of  tlie  astragalus  is  taken,  much  difficulty  will  be  met  in  re- 
moving tiie  upper  articular  surface.  Thus,  unless  the  saw  be  directed  properly,  the 
astragalo-scaptioid  or  astragalo-calcanean  joints  maybe  opened.  To  meet  the  difficulty 
of  fixing  the  foot  the  heel  should  be  held  in  the  left  hand,  and  the  upper  surface  of 
the  astragalus  is  pressed  against  the  cut  end  of  the  tibia,  while  an  assistant  holds  the 
leg  firmly  on,  and  a  little  over,  the  edge  of  the  table  (Porter,  Brit,  Med.  Journ.,  IS'S, 
vol.  ii.  p.  792). 


950  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

tendons  being  drawn  aside  while  the  bones  are  sawn.  Any  dead  bone 
is  gouged  away  and  pulpy  tissue  removed,  as  mentioned  above. 
Haemorrhage  being  arrested,  several  of  the  divided  tendons — e.g.,  the 
tibialis  anticus,  two  or  three  of  the  extensor  tendons — are  sutured 
with  chromic  gut  or  carbolized  silk. 

In  either  of  the  above  operations  every  care  must  be  taken  to  pre- 
serve the  periosteum,  especially  where  this  is  softened  and  loosened. 

A  suitable  splint  is  always  a  difficulty  in  these  cases.  On  the 
whole,  a  back  splint  and  foot-piece,  and  two  side  splints,  all  being 
padded  with  gauze,  will  be  found  most  suitable  for  the  first  ten  or 
fourteen  days  ;  the  side  splints,  being  secured  with  straps  and  buckles, 
readily  admit  of  removal  so  as  to  change  the  dressings.  If  all  the 
disease  has  been  taken  away,  and  due  drainage  provided,  the  dress- 
ings will  need  changing  very  infrequently.  After  the  first  fortnight 
the  limb  may  be  put  in  Mr.  Croft's  method  of  plaster-of- Paris,  or  with 
plaster-of-Paris  and  a  Nathan  Smith's  metal  bar  shaped  to  the  leg 
and  instep,  with  two  windows  at  the  sides  or  one  anteriorly.  Another 
arrangement  which  answers  well  with  a  quiet  patient  is  to  put  up  the 
limb  on  its  outer  side,  with  the  knee  flexed,  on  an  outside  angular 
splint  interrupted  opposite  the  wound,  the  splint  being  duly  sup- 
ported with  pillows.  If  the  external  wound  is  left  freely  open,  this 
method  gives  good  drainage. 

EXCISIONS  OF  BONES  AND  JOINTS  OF  TARSUS. 

Before  considering  these  separately,  I  would  invite  attention  to  the 
following  practical  points : 

i.  Those  cases  are  the  least  hopeful  in  which  there  is  no  history  of 
injury,  in  winch  there  is  evidence  of  a  strumous  constitution,  or  per- 
haps of  disease  dating  to  an  exanthem  and  coupled  with  the  above 
constitution;  cases  in  which  the  patient  is  wan  and  sickly  with  long 
lasting  pain  and  sleeplessness ;  cases  in  which  the  parts  are  much 
swollen,  dusky  red,  and  glossy,  with  sinuses  numerous  or  excavated, 
giving  vent  to  watery,  ill-smelling  discharge — all  points  denoting  a 
disease  that  is  not  limited  to  one  joint  or  to  few  bones. 

ii.  Mere  laying  open,  and,  still  more,  injection,  of  sinuses  where 
there  is  disease  of  the  tarsus  is  absolutely  useless  in  most  cases. 

iii.  When  a  patient  is  under  care  for  caries  of  the  foot,  his  lungs 
should  always  be  carefully  examined  before  operative  treatment  is 
undertaken. 

iv.  When  the  amount  of  disease  present  is  being  estimated,  it  must 
be  remembered  that  patients,  especially  children,  will  often  use  their 
feet  with  much  freedom,  limping,  even  bearing  their  weight  on  their 
toes  with  the  aid  of  a  crutch,  though  all  the  time  extensive  disease  is 
present. 


EXCISION    OF    THE    ASTRAGALUS.  951 

V.  That  before  an  operation  the  parts  should  always  be  rendered 
absolutely  evascular  by  the  use  of  Esmarch's  bandages,*  and  that 
thus  the  limit  of  the  disease  should  be  defined  as  accurately  as 
possible. 

vi.  Sub-periosteal  excision  is  only  advisable  in  the  case  of  single 
bones  where  the  periosteum  is  already  thickened  and  loosened,  and 
that  in  other  cases  it  is  not  of  such  great  advantage  as  to  justify  any 
considerable  prolongation  of  an  operation. 

vii.  Strict  antiseptic  precautions  should  be  made  use  of  wherever 
this  is  possible,  because — (a)  Prolonged  suppuration  will  exhaust  a 
patient,  whose  powers  are  already  suflficiently  handicapped  by  dis- 
ease and  operation;  (b)  suppuration  will  cause  destruction  of  the 
periosteum,  and  thus  fresh  caries  and  necrosis;  (c)  interference  with 
inflamed  bones  may,  if  sepsis  result,  easily  cause  osteo-myelitis  and 
pysemia. 

viii.  When  the  question  arises  between  excision  and  amputation, 
when  the  powers  of  repair  have  been  duly  considered,  the  question  of 
time  and  the  rank  of  life  should  also  be  remembered.  Thus,  after  an 
extensive  excision,  six  months  will  probably  be  required  before  the 
loot  can  be  used,  but  only  three  months  after  an  amputation.  The 
time  in  the  first  case  may  after  all  be  wasted,  a  point  of  much  impor- 
tance when  the  questions  of  schooling,  learning  a  trade,  etc.,  have  to  be 
considered. 

ix.  No  use  of  a  foot  can  be  permitted  after  an  operation  till  firm 
consolidation  is  obtained. 

X.  If  pulpy  mischief  persist  after  an  operation,  the  sharp  spoon 
must  be  freely  used,  together  with  laying  open  sinuses,  snipping  away 
of  undermined  skin,  etc.  If  all  carious  bone  has  been  removed,  the 
above  steps  may  be  repeated  again  and  again  here,  as  in  th^  knee, 
with  ultimate  success. 

EXCISION  OF  THE  ASTRAGALUS.f 

Indications  — These  will  be  for  A.  Disease,  B.  Injury.  Both  are 
rare. 

A.  Disease. — (1)  Caries  of  the  bone,  especially  when  comparatively 

*  This  is  disputed  by  some.  I  strongly  advise  it.  The  free  oozing  after  this 
method  may  be  met  by  tying  any  vessels  which  are  seen  in  the  absolutely  dry  wound, 
and  then  plugging  this  with  strips  of  sal-alembroth  or  iodoform  gauze,  around  a 
draiuage-tube,  bandaging  firmly  over  well-applied  dressings  before  the*  Esmarch's 
bandage  is  removed,  and  giving  sufficient  morphia  in  the  first  twelve  hours.  This 
dressing  will  seldom  require  removal  for  several  days,  when  the  strips  nuist  be 
thoroughly  soaked  before  removal. 

f  A  good  instance  of  the  occasional  value  of  this  operation  has  been  given  by  my 
old  friend  George  Wright  (Pendlebury  Abstracts,  1884,  p.  124).     Tlie  case  was  one  of 


952  OPERATIONS   ON   THE   LOWER   EXTREMITY. 

recent  and  of  traumatic  origin  in  a  young  and  healthy  patient,  and 
Avhen  the  disease  is  found  to  be  limited  to  the  upper  surface.  (2)  In 
disease  of  the  astragalo-calcanean  joint,  where  it  is  thought,  from  the 
position  of  the  sinuses,  etc.,  to  be  more  advisable  to  expose  this  joint 
by  removing  the  astragalus  than  the  os  calcis.  (3)  Talipes :  excision 
of  the  astragalus  for  these  affections  has  been  mainly  replaced  by 
removal  of  wedges  of  bone  (p.  956), 

B.  Injury. — (1)  Primarily,  (a)  In  simple  dislocation  of  the  astrag- 
alus not  reducil)le  with  the  aid  of  ansesthetics  and  tenotomy  of  the 
tendo-Achillis  and  the  tibials  or  extensors,  if  it  seem  certain  that  the 
skin  will  slough.  (/>)  In  compound  dislocation  of  the  astragalus 
when  the  bone  is  too  far  displaced  or  comminuted  to  admit  of  re- 
placement, and  when  the  condition  of  the  soft  parts,  vessels,  and 
tendons  does  not  call  for  amputation.  Secondarily,  when  the  foot  is 
useless  and  painful.  In  these  cases,  especially,  strict  antiseptic  pre- 
cautions must  be  taken  and  free  drainage  provided. 

Operation. — This  may  be  performed  by  two  lateral  or  a  transverse 
incision,  with  suture  of  the  tendons.  On  account  of  the  freer  exposure 
given,  I  prefer  the  latter.  The  parts  being  rendered  evascular,  the 
bone  is  exposed  by  an  incision  crossing  the  dorsum  between  the 
malleoli,  as  in  Syme's  amputation ;  the  tendons  are  cleanly  cut,  and 
the  astragalus  exposed.  At  this  stage  all  that  may  be  required  is  to 
remove  a  sequestrum  from  the  upper  surface  of  the  neck  of  the  bone. 
The  ligaments  must  be  divided  by  carefully  keeping  the  knife  close 
to  the  bone*  while  this  is  twisted  out  in  the  grasp  of  lion-forceps, 
aided,  if  needful,  by  the  levering  movements  of  an  elevator.f  If  the 
astragalo-calcanean  joint  is  found  diseased,  this  must  be  now  attended 
to  with  chisel,  gouge,  and  sharp  spoon.  The  scaphoid  is  next  ex- 
amined. All  pulpy  material  being  removed,  haemorrhage  is  arrested,]; 
the  chief  tendons  sutured,  and  the  centre  of  the  wound  closed,  the 
sides  being  left  open  for  drainage. 

severe  talipes  valgus,  due  to  infantile  paralysis  of  a  year's  stan  ling.  The  reaction  of 
the  muscles  to  Faradism  was  extremely  poor.  '"The  deformity  clearly  depended  on  a 
partial  siib-astragaloid  dislocation."  The  bone  was  removed  by  an  incision  along  the 
inner  border  of  the  tibialis  anticns,  and  a  shorter  one  meeting  this  between  the  tibialis 
anticus  and  posticus.  No  tendons  were  cut;  one  small  vessel  required  twisting.  The 
foot  could  be  inverted  into  good  position  after  removal  of  the  bone.  Twelve  months 
later  the  child  could  walk  painlessly  and  much  more  freely,  without  eversion,  and 
with  a  good  arch. 

*  Especially  at  the  back  and  on  the  inner  side. 

t  Care  must  be  taken  in  using  this  not  to  bruise  any  soft  bone  which  is  used  as  a 
fulcrum. 

X  The  dorsalis  pedis  should  be  secured,  and  oozing  met  by  plugging  the  wound 
with  strips  of  sal-alembroth  gauze  and  iodoform,  the  ends  of  the  strips  being  brought 
out  at  the  sides. 


EXCISION    OF   THE   OS    C ALOIS.  953 

Mr.  Barker  (Man.  of  Surg.  Oper.,  p.  175)  recommends  an  incision 
running  from  just  above  the  tip  of  the  external  malleolus  forwards 
and  a  little  inwards,  curving  towards  the  dorsum  of  the  foot.  This 
will  cross  a  space  between  the  peronsei  tendons,  in  which  no  struc- 
tures of  much  importance  are  found,  and  may  go  straight  down  to 
the  bone  at  once.  If  the  foot  is  now  turned  well  inwards  and  ex- 
tended, the  astragalus  is  easilj''  exposed  and  removed. 

EXCISION  OF  THE  OS  GALOIS. 

Practical  Remarks. — Disease  here  is  not  infrequent,  and  often 
remains  limited  to  this  bone  for  a  long  time.  It  may  commence  in 
one  of  three  sites — viz.,  (a)  the  posterior  epiphysis,  which,  not  appear- 
ing until  the  tenth  year,  does  not  unite  till  between  the  fifteenth  and 
nineteenth  years ;  (b)  the  body  of  the  bone ;  (c)  the  calcaneo-astraga- 
loid  joint,  either  de  novo,  or  as  an  extension  of  the  last.  The  diagnosis 
of  primary  disease  in  this  joint  is  often  difficult;  thus  the  swelling 
and  position  of  the  sinuses  recall  disease  of  the  ankle-joint.  The  pain 
is  usually  greater  than  in  ordinary  disease  of  the  os  calcis  itself,  and 
the  foot  is  sooner  disabled.  With  an  anaesthetic,  the  ankle-joint  is 
found  free,  and  probes  introduced  by  sinuses  may  pass  towards  the 
level  of  the  upper  surface  of  the  os  calcis  (known  by  the  tubercle  for 
the  extensor  brevis). 

Operation. — The  parts  being  rendered  evascular  and  the  foot 
firmly  supported  on  its  inner  side  at  the  edge  of  the  table,  an  in- 
cision* is  made  with  a  strong-backed  scalpel,  commencing  at  the 
inner  edge  of  the  tendo-Achillis,  and  passing  along  the  upper  border 
of  the  OS  calcis  {vide  supra)  along  the  outer  border  of  the  foot  as  far 
as  the  calcaneo-cuboid  joint,  Avhich  lies  midway  between  the  outer 
malleolus  and  the  fifth  metatarsal  bone.  This  incision  should  go 
down  at  once  upon  the  bone,  so  that  the  tendon  should  be  felt  to 
snap  as  the  incision  is  commenced.  Another  incision  is  then  to  be 
drawn  vertically  across  the  sole,  commencing  near  the  anterior  end  of 
the  first  and  terminating  just  short  of  the  inner  surface  of  the  os 
calcis,  beyond  which  it  should  not  extend  for  fear  of  wounding  the 
posterior  tibial  vessels.  The  bone  being  now  exposed  by  throwing 
back  the  flap,  the  calcaneo-cuboid  joint  is  first  found  and  oj^ened. 
The  peronaei  must  be  dissected  outf  and  drawn  aside  with  a  blunt 
hook.     The  astragalo-calcanean  joint  is  next  attacked,  and  the  close 

*  The  above  incision  is  taken  from  Mr.  Holmes's  article,  Syst.  of  Surg.,  vol.  iii. 
p.  771. 

t  Mr.  Holmes  (loc.  supra  cit )  says  that  he  has  always  divided  these  without  ill 
effect.  Care  must  be  taken  in  drawing  them  aside,  for,  if  this  is  done  too  vigorously, 
one  may  slough,  as  happened  to  me  in  one  of  my  cases. 


954  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

connection  between  the  bones  at  this  point  constitutes  the  principal 
difficulty  of  the  operation,  unless  the  joints  have  been  destroyed  by 
disease.  This  difficulty  can  best  be  met  by  grasping  the  bone  firmly 
with  lion-forceps,  and  wrenching  it  backwards  and  outwards,  aided 
by  levering  movements  of  an  elevator,  and  a  knife-point  kept  very 
close  to  the  bone.  Especial  care  must  be  taken  on  the  inner  side  to 
avoid  the  vessels.  The  bone  being  removed,  any  vessels  which  can 
be  seen  are  secured,  a  drainage-tube  is  inserted,  and  the  gap  around 
it  plugged  with  gauze. 

The  question  of  preserving  the  periosteum  has  already  been  re- 
ferred to,  p.  951.  Some  good  cases  of  excisions  of  tarsal  bones  are 
recorded  by  Mr.  Holmes,  Sjjst.  of  Surg.,  vol.  iii.  p.  769  et  seq.,  and  Surg. 
Treat,  of  Children's  Dls.,  chap.  xxiv. 

OPERATIONS  FOR  MORE  COMPLETE  TARSECTOMY. 

It  is  scarcely  worth  while  to  give  directions  for  the  removal  of  other 
single  bones — e.g.,  the  scaphoid  and  cuboid — as  these  are  rarely  dis- 
eased alone,  and,  if  this  should  be  so,  their  removal  is  easy. 

The  operations  of  Mickulicz  and  of  Dr.  P.  H.  Watson  will  be 
described  to  meet  those  cases  where  more  extensive  disease  is  present, 
and  where  the  patient's  age  and  condition  justify  a  trial  of  these 
severe  operations  instead  of  amputation. 

Operation  of  Mickulicz.*— The  object  of  this  operation  is  to 
procure  an  artificial  pes  equinus,  and  to  preserve  the  toes  and  meta- 
tarsals, these  being  brought  into  a  straight  line  with  the  leg  and  the 
toes  bent  at  a  right  angle,  so  that  the  patient  walks  on  the  ends  of  the 
metatarsal  bones  covered  by  the  thick  pads  of  tissue,  which  invest  them ; 
a  broader  surface  of  support  is  provided  than  after  Syme's  or  Piro- 
goff's  amputations,  and  there  is  some  elasticity  of  the  foot  left.  It  is 
especially  indicated  in  cases  where  the  bones  of  the  heel  and  the  soft 
parts  covering  them  are  extensively  diseased. 

Sir  W.  MacCormac's  patient  was  aged  fifteen,  and  the  disease  dated 
to  a  sprain  of  the  ankle.  On  the  lad's  admission  the  swelling  and 
sinuses  pointed  to  disease  of  the  os  calcis ;  later  on,  the  ankle-joint 
became  involved.  Amputation  being  refused.  Sir  W.  MacCormac 
operated  thus :  "  The  patient  was  placed  in  the  prone  position.  If 
it  be  the  right  foot,  the  knife  is  introduced  on  the  inner  border  of 
the  foot,  just  in  front  of  the  scaphoid  tubercle,  and  a  transverse  in- 
cision, extending  to  the  bone,  is  made  across  the  sole  to  a  point  a 
little  behind  the  tuberosity  of  the  fifth  metatarsal.     On  the  left  foot 

*  The  account  of  this  is  taken  from  a  paper  of  Sir  W.  MacCormac  (Lancet,  May  5, 
1888),  four  figures  accompanying  this.  Mickulicz's  paper  will  be  found  in  Langen- 
beck's  Arch.,  1881,  Bd.  xxvi.  S.  191. 


TAESECTOMY.  955 

the  direction  of  this  incision  will  be  reversed.  From  the  inner  and 
outer  extremities  of  the  wound  incisions  are  prolonged  upwards  and 
backwards  over  the  corresponding  malleolus,  and  their  extremities 
united  by  a  transverse  cut  across  the  back  of  the  leg,  down  to  the 
bone,  at  the  level  at  which  it  is  to  be  sawn,  usually  immediateh^ 
above  the  joint  surface  of  the  tibia.  In  cases  where  a  larger  removal 
of  the  tibia  and  fibula  is  required,  the  lateral  incision  must  be  more 
oblique,  and  the  posterior  transverse  cut  made  at  a  higher  level.  The 
ankle-joint  is  now  opened  from  behind,  the  disarticulation  completed, 
and,  after  flexing  the  foot,  the  soft  parts  are  carefully  separated  in 
front  until  the  medio-tarsal  joint  is  reached,  through  which  disarticu- 
lation is  effected  as  in  Chopart's  amputation.  The  heel  portion  of  the 
foot,  consisting  of  the  astragalus,  calcis,  and  the  soft  parts  covering 
them,  is  thus  removed.  The  articular  surfaces  of  the  tibia  and  fibula, 
with  the  malleoli,  are  now  sawn  ofl^,  as  well  as  those  of  the  cuboid  and 
scaphoid.  The  anterior  portion  of  the  foot  remains  connected  with  a 
bridge  of  soft  parts.  The  blood-supply  appears  to  l)e  ample,  for 
almost  direct! _y  after  the  amputation  blood  issues  freely  from  the  distal 
ends  of  the  divided  plantar  arteries.  All  ha?morrhage  having  been 
arrested,  the  foot  was  brought  into  straight  line  with  the  leg,  and  the 
cut  surfaces  of  the  bone  were  sutured  together  with  kangaroo  tendon. 
The  attempt  to  discover  and  unite  the  divided  ends  of  the  posterior 
tibial  nerve  failed,  on  account  of  the  sodden  condition  of  the  soft 
parts.  Suitable  dressings  and  a  plaster-of-Paris  splint  were  applied, 
the  toes  being  brought  into  a  position  of  complete  dorsal  flexion." 

The  boy  made  an  excellent  recovery.  Firm  bony  union  took  place. 
In  about  a  month  sensibilit}^  began  to  return  in  the  sole  and  grad- 
ually became  more  complete.     The  toes  were  mobile.* 

Operation  of  Watson. — This  is  adapted  to  cases  where  the  medio- 
tarsal  articulation  is  involved,  the  importance  of  which,  from  tlie 
number  of  bones  and  the  complicated  synovial  membrane,  is  well 
known  (p.  960).  In  other  words,  the  disease  should  be  situated  be- 
tween the  bases  of  the  metatarsal  bones  in  front  and  the  os  calcis  and 
the  astragalus  behind.  The  parts  being  rendered  evascular,  incisions  3 
to  4  inches  long  are  made,  on  the  outer  side,  from  the  centre  of  the  os 
calcis  to  the  middle  of  the  fifth  metatarsal  bone,  and  on  the  inner  from 
the  arch  of  the  astragalus  to  the  middle  of  the  first  metatarsal.  The 
soft  parts  are  carefully  dissected  off"  from  the  dorsal  and  plantar 
aspects  of  the  foot  by  means  of  these  incisions,  the  left  thumb  being 
kept  between  the  point  of  the  knife  and  the  bones.     With  a  curved 

*  The  patient  was  sliown  to  tlie  Medical  Society  more  tlian  a  year  after  tiie  Ofiera- 
tion.  "  lie  walked  up  and  down  the  room,  both  with  and  without  his  hoot,  witli  preat 
ease  and  evident  satisfaction  to  himself.  Tlie  union  is  quite  solid,  and  lie  now 
attends  to  his  daily  work  without  anv  inconvenience." 


956  OPERATIONS    ON    THE    LOWER    EXTREMITY., 

probe-pointed  bistoury  the  joints  between  the  astragalus  and  scaphoid, 
and  OS  calcis  and  cuboid,  are  opened  up,  and,  a  saw  being  passed  be- 
tween the  plantar  soft  parts  and  the  metatarsal  bones,  these  are  cut 
through  from  below  upwards.  The  diseased  bones  being  removed, 
the  wound  is  firmly  plugged  and  pressure  applied  with  gauze  pads  and 
bandages  before  the  tourniquet  is  removed.  That  this  operation, 
though  little  known,  is  an  excellent  one  in  Dr.  Watson's  hands  is 
shown  by  the  fact  that  five  out  of  his  six  cases  did  well.  It  must  be 
remembered  that  it  is  an  operation  in  the  dark,  and  one  that  may 
involve  a  good  deal  of  damage  to  soft  parts,  owing  to  the  amount  of 
disease  which  has  to  be  removed  by  somewhat  limited  incisions. 

REMOVAL  OF  TARSAL  BONES  FOR  INVETERATE 

TALIPES. 

The  removal  of  single  bones — e.g.,  the  cuboid  as  performed  by  Mr. 
Solly,  or  the  astragalas  by  Mr.  Lund — has  now  been  replaced  by  the 
resection  of  a  wedge  of  ]x)ne  from  the  outer  side,  an  operation  for 
which  we  are  indebted  to  Mr.  Davies-Colley  and  Mr.  Davy. 

Indications. — Cases  which  deserve  the  above  epithet  of  invete- 
rate, in  which  tenotomy  and  manipulation  have  been  thoroughly 
tried ;  cases  in  which  there  is  evidently  confirmed  alteration  in  the 
shape  of  the  bones — e.g.,  in  talipes  equino-varus — such  rigidity  that 
the  pasition  of  the  foot  cannot  be  possibly  altered,  the  astragalus  pro- 
jecting outwards  on  the  dorsum,  and  the  scaphoid  so  displaced  that 
it  almost  touches  the  internal  malleolus  ;  where  the  patient  walks  on 
the  outer  border  of  his  foot,  and  large  bursaj  have  formed  over  the 
cuboid  \  and  where  the  patient  is  prevented  from  earning  his  liveli- 
hood. Finally,  the  surgeon  must  feel  assured  as  to  his  power  of 
conducting  the  case  antiseptically. 

Operation. — The  parts,  being  rendered  evascular  with  Esmarch's 
bandages,  are  duly  cleansed  and  supported  on  a  sand-bag.  A  T-shaped 
incision  is  then  made  with  the  horizontal  limb  along  the  outer  side 
of  the  foot  over  the  os  calcis  and  the  cuboid,  and  the  longitudinal 
one  at  a  right  angle  to  this  passing  across  the  dorsum  and  ending 
over  the  scaphoid.  The  flaps  thus  marked  out  are  turned  aside. 
With  a  periosteal  elevator  the  tendons  and  vessels  in  the  dorsum  are 
now  raised  so  that  sufficient  room  is  given  for  the  saw  to  pass  between 
them  and  the  bones.  With  a  retractor  on  the  other  side  the  peronsei 
tendons  are  held  out  of  the  way,  due  care  being  taken  of  their  sheaths 
to  avoid  the  risk  of  sloughing.  With  a  narrow-bladed  saw  or  a 
chisel,  a  wedge  of  bone  is  then  removed  by  two  cuts,  one  above  and 
one  below,  meeting  at  the  scaphoid.  The  upper  of  these  will  pass 
through  the  os  calcis  to  the  scaphoid,  the  lower  through  the  cuboid, 
through  the  joint  between  this  and  the  fifth  metatarsal,  or  through 


chopart's  amputation.  957 

the  base  of  this  bone,  according  to  the  severity  of  the  case.  "While 
these  sections  are  made,  a  blunt  dissector  may  be  pushed  under  the 
bones  very  close  to  their  plantar  surfaces,  so  as  to  protect  the  soft 
parts  beneath.  The  wedge  of  bone  is  then  removed  with  a  lion- 
forceps,  or  by  levering  it  out  with  an  elevator,  care  being  taken  not 
to  damage  any  parts  used  as  a  fulcrum.  As  it  is  twisted  out,  a  few 
attachments  to  the  structures  in  the  sole  may  require  division  or  peel- 
ing off.  If  the  position  of  the  foot  cannot  be  rectified,  the  gap  must 
be  widened  by  removing  more  bone  either  with  a  saw  or  with  a  chisel 
and  mallet ;  it  is  especially  towards  the  apex  that  this  must  be  done.* 
When  the  foot  can  be  brought  into  good  position  any  tendons  that 
have  been  divided  are  united  with  carbolized  silk  or  chromic  gut. 
Any  vessels  which  can  be  seen  are  then  secured,  a  drainage-tube  is 
inserted,  and  the  wound  partly  closed  with  one  or  two  wire  sutures. 
Dressings  of  dry  gauze  are  then  firmly  bandaged  on  before  the  Es- 
march's  bandage  is  removed.  The  foot  is  put  up  with  a  back  and  two 
side  splints,  or  on  an  external  splint  with  an  interruption,  the  bone 
being  flexed  and  the  limb  resting  on  its  outer  side.  Mr.  Davy  has 
devised  a  special  splint  to  secure  eversion.  Morphia  should  be  given 
freely  at  first  if  required.  In  six  or  eight  weeks  the  union  should  be 
firm. 

Great  care  must  be  taken  during  the  after-treatment  to  keep  the 
parts  aseptic.  Mr.  Davy  lost  one  case,  two  weeks  after  the  operation. 
from  septicaemia  (^Brit.  Med.  Journ.,  1879,  voL  i.  p.  221),  Occasionally 
complete  closure  of  the  wound  is  delayed  b}^  the  coming  away  of  a 
scale  of  bone ;  the  ill-vitalized  corns  and  bursal  tissues  ma}'  show 
some  signs  of  sloughing.f 

CHOPART'S  AMPUTATION  (Figs.  190,  191,  192). 

In  this  medio-tarsal  amputation  only  the  astragalus  and  the  os 
calcis  are  retained,  disarticulation  being  efiected  through  the  joints 
between  the  above  bones  and  the  scaphoid  and  the  cuboid. 

Value  of  the  Operation. — This  has  been  a  good  deal  disputed. 
The  following  objections  have  been  raised  to  it : 

1.  That  the  tendo-Achillis,  no  longer  counterbalanced  bv  the 
extensor  muscles  which  have  now  lost  their  attachment,  draws  up  the 
heel,  tilting  down  the  scar,  which  now  becomes  tender  and  irritable. 

2.  In  the  normal  foot  the  weight  of  the  body  is  transmitted  through 

*  Some  contracted  tendons  may  now  require  division  before  tiie  inversion  can  be 
completely  overcome.     The  tendo-Achiliis  may  be  divided  now  or  later. 

f  In  a  case  of  Mr.  Bennett's  {Clin.  Soc.  Trans.,  vol.  xv.  p.  83)  erysipelas  attacked 
the  sinus,  which  was  all  tiiat  remained  of  the  wound,  and  all  the  union  between  the 
bones,  which  had  been  very  firm,  gave  waj.     Tlie  case  ultimately  did  welL 


&68  OPERATIONS    ON   THE    LOWER    EXTREMITY. 

the  astragalus  to  the  other  bones  of  the  tarsus  and  metatarsus.  When, 
as  in  this  amputation,  these  bones  have  been  removed,  the  weight  of 
the  body  tends  to  thrust  forward  the  astragalus,  no  longer  supported 
by  the  elastic  bones  in  front,  against  the  scar,  and  thus  renders  this 
tender  and  crippling. 

The  above  objections  apply  to  the  operation  performed  for  injury 
or  disease,  the  next  to  amputation  for  the  latter  only, 

3.  If  the  operation  be  made  use  of  in  caries,  this  disease  is  likely  to 
recur  in  the  two  bones  left. 

In  answer  to  the  first  two  of  the  above  objections  it  may  be  said 
that  this  tendency  to  tilting  upwards  of  the  heel  and  downwards  of 
the  scar  may  be  met :  (a)  By  stitching  the  anterior  tendons — e.g., 
tibialis  anticus,  extensor  proprius  pollicis,  and  some  of  the  tendons 
of  the  extensor  communis — into  the  tissues  of  the  sole-flap with  stout 
carbolized  silk  or  chromic  gut,  so  as  to  give  them  a  fixed  point  by 
which  they  may  counterbalance  the  tendo-Achillis  ;*  (h)  by  cutting 
the  plantar  flap  sufficiently  long,  and  securing  firm  primary  union ; 
(c)  by  division  of  the  tendo-Achillis.  This,  however,  is  only  of 
fugitive  value. 

The  third  objection  is  answered  by  never  performing  the  operation 

Fig.  190. 


Incisions  in  Chopart's  amputation.    (Fergusson.) 

for  caries,  unless  of  distinctly  traumatic  origin,  and    in  a  healthy 
patient. 

Operation  (Figs.  190,  191\ — An  Esmarch  being  applied  round  the 
leg,  and  the  foot  supported  at  a  right  angle  over  the  edge  of  the  table, 
the  surgeon,  standing  to  the  right  side  of  the  foot,  and  so  that  he  can 
easily  face  the  sole,  places  {e.g.,  on  the  right  side)  his  left  index  and 
thumb  immediately  behind  the  tubercle  of  the  scaphoid  and  the  cor- 

*  We  owe  this  ingenious  precaution  to  Mr.  Delagarde,  of  Exeter.  Till  it  is  more 
frequently  made  use  of,  and  a  larger  number  of  cases  are  collected,  the  value  of  this 
operation  must  remain  somewhat  undecided.  In  two  cases  of  Chopart's  amputation 
of  mine — one  a  severe  crush,  and  the  other  for  the  results  of  perforating  ulcer — in 
which  this  precaution  was  taken,  the  stumps  proved  sound  and  useful. 


chopart's  amputation. 


959 


responding  point  on  the  outer  side — viz.,  the  calcaneo-cuboid  joint, 
which  lies  midwaj^  between  the  external  malleolus  and  the  base  of 
the  fifth  metatarsal  bone.  He  then  joins  these  points  by  a  slightly 
curved  incision  crossing  the  tarsus,  and  dividing  everything  down  to 
the  bones.  The  foot  being  flexed  upwards,  a  plantar  flap  is  then 
marked  out  by  an  incision  running  from  the  outer  extremity  of  the 


Fig. 191. 


Fig.  19?. 


stump  after  Chopart's  amputation.    (Fergusson.) 


first  up  the  outer  side  of  the  little  toe,  then  across  the  sole,  along  the 
roots  of  the  toes,  and  then  down  the  inner  side  of  the  great  toe  to  join 
the  inner  extremity  of  the  first.  The  flap  thus  marked  out  is  raised 
with  the  same  precautions  given  at  p.  961.  It  is  then  held  out  of  the 
way,  and  the  anterior  half  of  the  foot  being  strongly  depressed,  dis- 
articulation is  effected  by  passing  the  knife  behind  the  tubercle  of  the 
scaphoid  between  this  bone  and  the  astragalus,  and  then  between  the 
OS  calcis  and  cuboid.  In  effecting  this  the  position  of  the  joints  and 
the  shai3e  of  the  astragalus  must  be  remembered,  and  Mr.  Skey's  words 
borne  in  mind  :  "  The  joints  should  be  opened  with  tact  and  not  by 
force :  if  the  knife  be  applied  to  the  right  surface,  it  will  pass  without 
effort  into  the  articulation ;  if  in  the  wrong  direction,  no  force  will 
effect  it."  ■ 

The  anterior  tibial  and  plantar  arteries  are  then  secured,  and,  on 
removal  of  the  Esmarch's  bandage,  any  other  vessels  which  require  it. 
The  flap  is  then  folded  up  over  the  bones,  but  without  any  forcible 
bending,  which  might  interfere  with  the  blood-supply.  AVhile  it  is 
held  in  this  position,  before  any  sutures  are  inserted,  the  extensor 
tendons  (vide  supra)  should  be  carefully  stitched  into  the  fibrous 
tissues,  which  abound  in  the  heel-flap,  care  being  taken  in  so  doing 
not  to  puncture  the  external  plantar  vessels. 


960  OPERATIONS   ON   THE   LOWER   EXTREMITY. 


AMPUTATION  THROUGH  TARSO-METATARSAL 
JOINTS  (Fig.  liJ8). 

This,  though  usually  spoken  of  as  Hey's  or  Lisfranc's  amputation, 
includes,  accurately  speaking,  the  following  operations  : 

1.  Lisfranc's. — Amputation  by  disarticulation  through  all  the 
joints. 

2.  Hey's. — This  is  usually  described  as  amputation  here  by  sawing 
through  the  bases  of  the  metatarsals.  In  reality,  Hey  seems  to  have 
disarticulated  through  the  outer  four  joints,  and  sawn  off  the  project- 
ing internal  cuneiform.* 

3.  Skey's.t — Disarticulation  through  the  outer  three  and  the  first 
joints,  the  base  of  the  second  metatarsal  being  sawn  off. 

Indications. — Few.  (1)  Limited  crushes  in  which  the  sole  is 
sound.  (2)  Disease  limited  to  the  front  of  the  foot.  (3)  Inveterate 
bunion,  with  persistent  sinuses  and  recurrent  attacks  of  cellulitis. 
(4)  Perhaps  perforating  ulcer.     (5)  Some  cases  of  frost-bite. 

Owing  to  the  complexity  of  the  synovial  membrane  here,  any  dis- 
ease which  has  invaded  the  synovial  membrane  between  the  second 
and  third  metatarsals  and  the  second  and  third  cuneiforms,  has  also 
spread  to  that  between  the  scaphoid  and  three  cuneiforms.  This, 
though  of  small  moment  in  cases  of  injury,  should  put  this  amputa- 
tion aside  in  most  cases  of  disease. 

Lisfranc's  Amputation  (Fig.  193). — The  preliminaries  are  the 
same  as  in  Chopart's  amputation.  The  surgeon,  standing  to  the  right 
side  of  either  foot,  and  so  as  easily  to  face  the  sole,  places  his  left 
index  and  thumb  in  the  bases  of  the  little  and  great  toe  metatarsals 
respectively.  The  first  of  these  can  always  be  found  by  pressure,  even 
if  swelling  is  present ;  if  there  be  any  difficulty  with  the  latter,  it  will 
be  found  a  full  inch  in  front  of  the  readily  detected  tubercle  of  the 
scaphoid.  These  two  points  thus  marked  out  are  joined  by  a  slightly 
curved  incision  with  its  convexity  forwards.  As  a  rule,  if  the  tissues 
in  the  sole  are  sound,  no  dorsal  flap  should  be  made,  the  above  in- 
cision being  kept  close  to  the  line  of  the  joints  through  which 
disarticulation  is  to  be  performed. 

The  foot  being  now  flexed  upwards,  the  surgeon,  looking  towards 
the  sole,  marks  out  a  plantar  flap  by  an  incision  running  from  the 
outer  extremity  of  the  first  cut  (for  the  left  foot)  up  the  outer  side  of 
the  foot,  then  across  the  heads  of  the  metatarsals,  and  down  the  inner 
side,  so  as  to  join  the  inner  extremity  of  the  dorsal  incision.  This 
flap  should  be  made  a  little  longer  on  the  inner  than  on   the  outer 

*  Observations  in  Surgery,  3d  edition,  p.  552. 
f   Oper.  Surg.,  p.  406. 


AMPUTATION    THROUGH    THE    METATARSAL    JOINTS. 


961 


side  of  the  foot,  so  as  to  cover  the  additionally  projecting  bones  on 
this  side.  Its  cut  edge  being  taken  firmly  between  the  finger  and 
thumb,  the  flap  is  then  dissected  up  as  thickh^  as  possible — i.e.,  con- 
taining all  the  tissues  possible  in  the  sole.     In  keeping  the  knife  close 

Fig.  193. 


Disarticulation  of  the  second  metatarsal  in  Lisfranc's  amputation.    The  knife  is  being 
used  as  described  below,  to  separate  the  second  from  the  first  metatarsal' bone. 


to  the  bones  some  of  the  metatarso-phalangeal  joints  will  probably  be 
opened.  Below  these  the  flap,if  steadil}^  pulled  upon,  will,  with  light 
touches  of  the  knife,  readily  separate  from  the  metatarsal  bones.  The 
flap  should  be  raised  evenly,  and  without  scoring  or  any  button-holes. 
The  prominent  bases  of  the  first  and  fifth  metatarsals  being  laid  bare, 
a  few  strong  touches  of  the  point  of  the  knife  may  be  required  to 
separate  part  of  the  tibialis  anticus  and  peronseus  longus  from  the 
base  of  the  former.  The  anterior  part  of  the  foot  is  now  strongly 
depressed  so  as  to  stretch  the  dorsal  ligaments,  and  the  knife,  having 
been  thoroughly  carried  round  the  base  of  the  fifth  metatarsal,  is 
drawn  obliquely  forwards  and  inwards  so  as  to  open  the  joints  of  the 
outer  three  metatarsals  with  the  cuboid  and  the  external  cuneiform. 
The  joint  between  the  first  metatarsal  and  the  internal  cuneiform  is 
next  opened,  and,  lastly,  the  second  metatarsal  is  next  freed  as  fol- 
lows :  The  knife  being  held  firmly  in  the  fist,  its  point  is  inserted 
between  the  first  two  metatarsal  bones,  and  the  knife  carried  back- 
wards and  forwards  in  an  antero-posterior  direction  in  the  long  axis 
of  the  foot  (Fig.  193),  The  same  is  then  done  between  the  second  and 
third  metatarsals,  and,  the  lateral  ligaments  being  thus  divided,  the 
joint  between  the  second  metatarsal  and  the  middle  cuneiform  is  then 

61 


962 


OPEEATIONS   ON   THE   LOWER   EXTREMITY. 


Fig.  194. 


stump  after  Lisfiane's  amputation. 
(Fergussoii.) 


found  and  opened  *  this  being  facilitated  by  strongly  depressing  the 
foot,  care  being  taken  not  to  do  this  so  violently  as  to  separate  the 
second  metatarsal  from  its  upper  epiphysis.f    A  few  remaining  touches 

of  the  knife,  aided  by  a  twisting 
movement,  will  then  suffice  to 
separate  the  foot. 

This  method  of  cutting  the 
plantar  flap  before  any  attempt 
is  made  to  disarticulate  is 
strongly  recommended  in  prefer- 
ence to  disarticulating  immedi- 
ately after  making  the  dorsal 
incision  by  passing  the  knife  be- 
hind the  bones  and  cutting  the 
flap  from  within  outwards.  In 
thus  disarticulatingbefore  making 
the  plantar  flap,  it  is  quite  possi- 
ble to  puncture  the  tissues  in  the  sole,  and  perhaps  to  wound  the 
external  plantar  artery.  Again,  passing  the  knife  behind  the  meta- 
tarsal bones  often  leads  to  a  hitch,  especially  with  the  projecting  fifth. 
The  dorsalis  pedis  and  the  external  plantar  artery  are  now  secured, 
with  any  smaller  vessels  which  need  it.  Tendons  are  cut  square, 
drainage  provided,  and  the  plantar  flap  then  brought  up  and  secured 
in  accurate  position. 

Owing  to  the  thickness  of  the  heel-flap  and  its  tendency  at  first  to 
unfold  itself  downwards,  numerous  points  of  suture,  of  sufficiently 
stout  wire  or  carbolized  silk,  must  be  made  use  of,  or  one  or  two  hare- 
lip pins  may  be  employed. 

AMPUTATION  OF  TOES. 

Practical  Points. — (1)  Any  plantar  scar  is  to  be  avoided.  (2) 
The  line  of  the  metatarso-phalangeal  joints  lies  a  full  inch  farther 

*  The  position  of  this  joint  mnst  be  remembered  and  the  way  in  which  the  base  of 
the  second  metatarsal  bone  is  locked  in  between  its  fellows  and  the  Cuneiform  bones. 
Its  base  projects  upwards  between  J  and  }  inch  above  the  others.  Prof.  Syme  gave 
this  rule  to  guide  the  surgeon  in  disarticulating  the  outer  three  metatarsals:  "Having 
once  entered  the  joint  of  the  fifth,  the  knife  must  be  drawn  along  in  the  direction  of  a 
line  drawn  towards  the  distal  end  of  the  first  metatarsal ;  for  the  fourth,  the  direction 
must  be  changed  for  the  middle  of  the  same  bone;  and  to  open  the  third  it  will  be 
necessary  to  come  across  the  dorsum  of  the  foot,  as  if  intending  to  reach  the  proximal 
end." 

f  While  the  surgeon  is  disarticulating  the  metatarsal  bones  the  plantar  flap  must  be 
held  well  out  of  the  way  to  prevent  its  being  punctured. 


AMPUTATION    OF   THE   GREAT   TOE.  963 

back  than  the  inter-digital  folds  of  the  skin*  (Holden).  (3)  Partial 
amputations  (save  in  the  case  of  the  great  toe)  are  very  seldom  advis- 
able, the  stumps  left  being  of  little  use,  and  inconvenient,  owing  to 
their  liabilit}'  to  stick  upwards. 

AMPUTATION  THROUGH  PHALANGES  OR  INTER- 
PHALANGEAL  JOINTS. 

These  operations  are  not  recommended,  for  the  reasons  just  given. 
If  a  patient  insist  on  having  one  performed,  the  directions  already 
given  for  the  fingers  (p.  20)  will  be  found  sufficient. 

AMPUTATION  OF  ANY  OF  THE  FOUR  SMALLER  TOES 
AT  THE  METATARSO-PHALANGEAL  JOINTS. 

This  amputation  is  performed  much  as  in  the  case  of  the  fingers 
(p.  22),  but  the  following  points  must  be  remembered : 

(1)  The  line  of  the  joint  lies  a  full  inch  above  the  web  (vide  siqva). 
(2)  The  head  of  the  metatarsal  bone  is  not  here  removed,  so  as  to 
leave  the  supporting  power  of  the  foot  undiminished.  (3)  It  is  most 
important  to  avoid,  as  far  as  possible,  any  sear  in  the  sole. 

The  scar,  a  simple  antero-posterior  one,  is  well  protected  by  the 
adjacent  toes.  The  incision  should  always  be  begun  on  the  dorsum, 
even  in  the  case  of  the  little  toe,  so  as  to  avoid  friction  of  the  boots. 

AMPUTATION  OF  GREAT  TOE  AT  INTER-PHA- 
LANGEAL  JOINT  (Fig.  195.) 

This  is  usually  performed  with  a  palmar  flap,  as  at  p.  18. 

AMPUTATION  OF  GREAT  TOE  AT  METATARSO- 
PHALANGEAL JOINT  (Fig.  195). 

This  is  performed  by  the  oval  method  described  at  p.  23.  The  fol- 
lowing points  must  be  borne  in  mind  : 

(1)  Owing  to  the  large  size  of  the  head  of  the  metatarsal  bone,  the 
flaps  are  often  cut  of  insufficient  length.  The  incision  must  be  begun 
li  inch  above  the  joint,  and  carried  well  on  to  the  jjhalanx,  one  flap 
being  cut  longer  than  the  other  if  needful.  (2)  The  sesamoid  bones 
must  be  left  in  connection  with  the  head  of  the  metatarsal  bone,  as 
any  attempt  to  dissect  them  out  is  likely  to  imperil  the  vascularity  of 
the  flap,  especially  after  middle  life. 

In  all  other  details  the  steps  of  this  amputation  are  very  similar  to 
those  already  given,  p.  22. 

*  According  to  Erichsen,  as  a  general  rule  it  will  be  found  that  these  articulations 
are  about  tlie  same  distance  above  the  web  as  tlie  point  of  the  toes  are  below  it.  This, 
1  think,  places  the  line  of  the  joints  too  high. 


964 


OPERATIONS   ON    THE    LOWER    EXTREMITY. 


Though  it  is  recommended  by  some  excellent  surgeons  to  remove 
the  head  of  the  metatarsal  bone  either  transversely  or  obliquely  from 


Fig.  195. 


Fig.  196. 


Amputation  of  great  toe  and  its  meta- 
tarsal bone.    (Fergusson.) 


The  foot  left  by  the  operation. 
(Fergusson.) 


within  outwards,  this  step,  narrowing  as  it  does  the  treading  width  of 
the  foot,  is  not  advisable,  unless  the  condition  of  the  skin  is  such  as 
to  render  it  impossible  to  obtain  sufficient  flaps  to  cover  the  entire 
head. 


CHAPTER  VII. 

OSTEOTOMY. 

OSTEOTOMY  OF  THE  FEMUR  FOR  ANKYLOSIS  OF 
HIP-JOINT— FOR  GENU  VALGUM.— OSTEOTOMY  OF 
THE  TIBIA.— OSTEOTOMY  FOR  DISPLACEMENT  OF 
THE  GREAT  TOE  IN  BUNION. 

FOR  ANKYLOSIS  OF  HIP-JOINT. 

This  includes  Adams's  operation  of  division  of  the  neck  of  the 
femur  and  Gant's  operation  of  division  of  the  shaft  of  the  femur 
just  below  the  trochanters.  The  latter  being  much  the  simpler,  and 
giving  excellent  results,  will,  I  think,  replace  the  former.  These  opera- 
tions are  intended  to  remedy  cases  in  which  the  hip-joint  is  perma- 
nently flexed  and  stiff,  and  the  patient  accordingly  crippled,  either  from 
old  hip  disease,  or  from  ankylosis  after  rheumatic  fever,  pyemia,  etc. ; 
cases  in  which  extension  has  failed,  together  with  trials  of  straighten- 
ing the  limb  with  the  aid  of  anaesthetics. 

Adams's  operation  divides  the  neck  of  the  femur  subcutaneously 
within  the  capsule.     It  is  best  suited  for  those  cases  in  which  the  neck 


OSTEOTOMY    FOR   AISKYLOSIS   OF    HIP-JOIXT.  965 

remains  unabsorbed,  as  in  ankylosis  after  rheumatic  fever  and,  much 
more  rarely,  pyemia.  A  long  tenotome  or  a  straight  narrow  bistoury 
is  entered  a  little  above  the  great  trochanter,  and  carried  straight  down 
to  the  neck  of  the  femur,  dividing  the  muscles  and  opening  the  capsule 
freely.  The  knife  being  withdrawn,  the  excellent  saw  which  bears  Mr. 
Adams's  name  is  passed  along  the  wound  made  down  to  the  neck  of 
the  bone,  which  is  then  sawn  through.  After  sawing  for  about  four  or 
five  minutes,  the  limb  should  become  movable.  If  this  is  not  the  case, 
the  section  has  been  made,  not  through  the  neck  itself,  but  through  the 
junction  of  the  neck  and  shaft. 

In  order  to  bring  down  the  limb  completely,  the  contracted  tendons 
of  the  adductor  longus,  sartorius,  and  perhaps  the  rectus  wdll  probably 
require  division  with  a  tenotome.  The  operation  should  be  conducted 
with  strict  antiseptic  precautions. 

The  limb  is  straightened  at  once,  and  put  up  with  a  long  outside 
splint — e.g.^  a  Desault's — and  a  little  morphia  given  subcutaneously. 
There  is  no  ha3morrhage,  and  the  wound  heals  quickly. 

This  operation  gives  good  results,  though,  as  I  have  said,  I  prefer 
Gan|;'s,  owing  to  its  greater  simplicity.  For  there  is  no  doubt  that  if 
the  bone  is  dense  from  previous  inflammation,  and  the  section  trenches 
upon  the  shaft  instead  of  going  through  the  neck  only,  the  sawing  may 
be  very  tedious.  Thus  I  have  twice  seen  cases  in  w^hich  this  took  over 
half  an  hour. 

A  case  is  mentioned  in  a  report  from  a  committee  of  the  Belgian 
Academy  of  Medicine,  in  which  a  patient  who  had  been  submitted  to 
Adams's  operation  insisted  on  getting  up  on  the  twentieth  day.  Haem- 
orrhage came  on  from  the  fragments  wounding  the  femoral  vessels  or 
some  large  branch.  The  femoral  was  tied  just  below  Poupart's  liga- 
ment; the  haemorrhage  ceased,  but  free  incisions  were  required  for 
suppuration.  The  patient  ultimately  recovered.  The  same  committee 
reported  a  death  from  haemorrhage,  and  one  from  purulent  infiltration. 
No  bad  results  have,  I  believe,  followed  in  England. 

Gant's  Operation.— Here  the  shaft  of  the  femur  is  divided  just 
below  the  trochanters.  Thus  the  operation  is  a  simpler  one  than  that 
just  given,  as  the  shaft  is  more  readily  reached  and  divided  than  the 
neck.  Furthermore,  it  is  an  operation  of  wider  applicability,  for  it  is 
suited  to  all  cases,  not  only  those  in  which  a  neck  remains,  but  those 
more  common  cases  of  ankjdosis  after  hip  disease,  in  which  repair  has 
taken  place  with  partial  displacement  of  the  head,  or  what  remains  of 
it.  The  fact  that  in  these  cases  there  is  next  to  no  neck  left  to  divide, 
makes  them  unsuited  for  Mr.  Adams's  operation. 

A  long  tenotome  or,  better,  a  sharp-pointed,  narrow,  straight  bistoury 
is  entered  just  below  the  great  trochanter,  and  made  to  divide  every- 
thing down  to  the  bone  as  it  is  lodged  upon  the  outer  aspect  of  the 


966  OPERATIONS    ON   THE    LOWER    EXTREMITY. 

anterior  surfjxce,  and  then  drawn  down  over  the  outer  surface  of  the 
shaft.  As  it  is  withdrawn  the  wound  is  a  little  enlarged  downwards. 
The  saw  is  then  introduced  along  the  wound  well  down  to  the  bone, 
and  the  outer  two-thirds  of  this  sawn  through,  the  rest  being  effected 
by  snapping  the  bone  by  lateral  movements.  The  same  tendons  will 
probably  require  division. 

In  neither  case  is  it  any  practical  good  to  try  and  secure  a  false  joint. 

OSTEOTOMY  FOR  GENU  VALGUM  (Figs.  197,  198,  199). 

Under  this  heading  the  following  operations  will  be  described  : 
I.  Division  of  the  Shaft  of  the  Femur  from  the  Outer 

Side. 
II.  Division  of  the  Lower  End  of  the  Femur  from  the 
Inner  Side,  just  above  the  Epiphysial  Line  (Mac- 
ewen). 

III.  Division  of  the  Internal  Condyle  Obhquely  (Ogston). 

IV.  Division  of  the  Lower  End  of  the  Femur  and  the 

Upper  End  of  the  Tibia  above  and  below  their 
respective  Epiphyses  (Barwell). 

I.  Division  of  the  Shaft  of  the  Femur  from  the  Outer  Side 
(Figs.  197, 198, 199). — The  limb  being  supported,  with  the  knee  flexed, 
on  a  sand-bag,  an  incision  about  an  inch  long  is  made  at  a  right  angle 
to  and  down  to  the  bone  on  its  outer  side  about  3  inches  above  the  ex- 
ternal condyle.  The  knife — a  narrow,  straight  bistoury — should  go 
down  to  the  bone  deliberately,  and  cut  firmly  and  strongly  on  it,  en- 
larging the  wound  slightly  as  it  emerges,  in  order  that  the  soft  parts 
may  not  be  damaged  if  the  heel  of  the  saw  is  depressed,  and  that  there 
may  be  no  lip  of  tissues  to  hinder  the  escape  of  discharges.  The  saw 
or  chisel  is  then  introduced,  and  the  bone  divided  for  its  outer  two 
thirds.  As  the  thicker  part  of  the  bone  is  on  the  outer  side,  as  soon 
as  this  is  divided  the  inner  third  usually  gives  way  readily  on  carrying 
the  knee  and  leg  from  Avithout  inwards.  But  the  operator  should  con- 
tinue the  division  of  the  bone  till  he  can  feel  certain  that  two  thirds 
are  divided,  for  if,  after  dividing  only  half,  he  tries,  especially  in  the 
case  of  a  dense  bone,  to  fracture  the  rest  and  straighten  the  limb,  either 
great  and  prolonged  force  must  be  made  use  of,  leading  probably  to 
irritation,  ceUulitis,  and  suppuration,  with,  perhaps,  necrosis,  or  the 
saw  or  chisel  must  be  re-introduced,  a  point  to  be  always  avoided  if 
possible,  as  the  difficulty  which  is  usually  met  with  in  hitting  off  the 
original  track  will  be  likely  to  lead  to  the  above  drawbacks. 

The  advantages  of  the  above  method  are  (1)  that  the  femur  is  divided 
at  a  much  narrower  part  than  in  the  supra-condyloid  operation  of 
Macewen,  and  that  thus  it  is  more  easily  and  quickly  done.     (2)  The 


OSTEOTOMY   FOR   GENU    VALGUM. 


967 


bone  section  is  farther  away  from  the  epiphysis,  and  the  line  of  the 
synovial  membrane,  in  case  subsequent  inflammation  takes  place.  (3) 
There  are  no  important  bloodvessels  near  (p.  972). 


Fig.  197.* 


Fig.  198.* 


Fig.  19P. 


Fig.  199.— The  transverse  line  on  the  shaft  of  the  femur  shows  the  site  of  division  of  the  bone 
from  the  outer  side.  Below  this  are  shown  Maeewen's  and  Ogston's  operations.  The  arrow  in- 
dicates the  direction  in  which  the  osteotome  is  worked  in  the  former.  The  line  on  the  tibia 
shows  the  site  of  division  of  the  bone  for  an  ordinary  rickety  curve.  This  curve  in  the  lower 
third  should  have  been  shown  more  marked,    (.\fter  Barker.) 

II.  Division  of  the  Lower  End  of  the  Femur  from  the  Inner 
Side,  just  above  the  Epiphysial  Line  (supra-condyloid  of  Mac- 
ewenfj  (Fig.  199). — The  knee  being  flexed  and  supported  firml}'  on  a 
sand-bag,  the  skin  cleansed,  the  position  of  the  adductor  tubercle  is 
defined,  and  a  longitudinal  incision  about  an  inch  long  (a  little  longer 
than  the  breadth  of  the  chisel  to  be  used)  is  made  down  to  the  bone 
at  a  point  where  the  two  following  lines  meet — viz.,  one  drawn  trans- 
versely a  finger's   breadth   above  the  superior  tip  of  the  external 

*  Double  genu  valgum  treated  by  division  of  tlie  shaft  of  the  femur  from  the  out- 
side. A  good  average  case,  both  as  to  its  severity  and  the  results  of  oijeration.  Some 
flat  foot  remains  on  tiie  leftside. 

t   Osteotomy,  p.  120. 


968  OPERATIONS   ON   THE    LOWER   EXTREMITY. 

condyle,  and  another  drawn  longitudinally  about  2  inch  anterior  to 
the  adductor  tubercle.  The  scalpel  goes  at  once  down  to  the  bone. 
Superficial  veins  may  be  cut,  but  no  artery  normally  distributed,  as 
the  incision  is  below  and  anterior  to  the  anastomotica  magna  and 
above  the  superior  internal  articular.  Before  withdrawing  the  knife, 
the  osteotome*  is  introduced  by  its  side  down  to  the  bone  in  the  same 
way  as  the  knife — i.e.,  parallel  to  the  long  axis  of  the  limb — is  then 
turned  at  a  right  angle  to  it,  and  the  inner  two-thirds  cut  through. 
TJic  direction  of  the  bone  incision  is  most  important.  The  surgeon  must 
cut  transversely  across  the  femur  on  a  level  with  a  line  drawn  5  inch 
above  the  tip  of  the  exterxial  condyle. f  Otherwise,  as  in  a  valgous 
limb  the  whole  internal  condyle  is  lowered,  a  line  drawn  transversely 
from  the  adductor  tubercle  might  land  the  operator  low  down  in  the 
external  condyle.  The  osteotome  must  be  driven  at  first  from  behind 
forwards  and  to  the  outer  side;  it  is  then  made  to  move  forwards 
along  the  inner  border  until  it  comes  to  the  anterior  surface,  when  it 
is  directed  from  before  backwards  and  towards  the  outer  posterior 
angle  of  the  femur.  By  keeping  on  these  lines  there  is  no  fear  of  in- 
jurying  the  artery.  The  hard  exterior  of  the  bone  usually  resists  the 
osteotome,  especially  in  adults,  but  several  strokes  cause  it  to  pene- 
trate this  superficial  dense  portion, J  when  the  instrument  will  pass 
easily  through  the  cancellous  bone.  The  surgeon  will  soon  recognize 
by  touch  or  by  hearing  when  the  osteotome  meets  the  hard  layer  on 
the  opposite  side.  If  it  be  thought  desirable  to  penetrate  tliis  outer 
dense  part,  it  must  be  done  very  steadily,  so  as  to  check  any  undue 
impetus  on  the  part  of  the  osteotome.  A  sponge,  wrung  out  of  1  in 
40  carbolic  lotion,  is  then  placed  over  the  wound  ;  the  surgeon,  grasp- 
ing this  and  the  limb  with  his  left  hand,  and  taking  the  limb  again 

*  In  adults  a  second,  or  even  a  third,  finer  instrument  may  be  used,  being  slipped  in 
ovv  tiie  first  as  this  is  withdrawn.     In  ciiildren  one  instrument  will  suffice. 

f  The  incision  above  given  will  avoid  the  epiphysis  and  synovial  membrane.  The 
line  of  the  former  may  be  usually  represented  by  one  crossing  tlie  femur  at  the  level 
of  the  highest  point  of  the  femoral  articulating  surface,  and  running  through  or  just 
below  the  adductor  tubercle,  so  that,  the  incision  being  an  inch  above  the  tubercle,  the 
epiphysis  will  be  cleared.  The  only  part  of  the  synovial  membrane  which  is  as  high 
as  the  bone  incision  is  that  imder  the  quadriceps,  wliich  may  reach  in  the  adult  as 
high  as  2  inclies  above  tiie  trocldear  surface.  It  is  somewhat  triangular  in  sliape,  its 
base  being  at  the  condyles,  and  it  gradually  tapers  to  the  middle  line  as  it  ascends. 
There  is  generally  a  quantity  of  fat  between  it  and  the  bone.  The  spot  selected  by 
Dr.  Macewen  for  his  incision  is  posterior  to  this  point. 

I  The  osteotomes  must  be  bevelled  on  both  sides,  wedge-like,  and  suflBcientiy  trust- 
worthy for  hardness  and  toughness,  points  only  to  be  secured  by  getting  them  of  first- 
rate  and  painstaking  makers.  Dr.  Macewen's  test  is  as  follows:  If  the  instrument  will 
heitiierturn  nor  chip  in  penetrating  the  thigh-bone  of  an  ox,  it  is  well  suited  for  cut- 
ting human  bones. 


OSTEOTOMY    FOR   GENU    VALGUM.  969 

lower  down  with  his  right,  gives  the  extended  limb  thus  held  a  quick 
jerk  inwards :  this  is  repeated  if  needful,  or  the  limb  may  be  carried 
outwards,  and  thus  broken  or  bent  sufficiently. 

III.  Division  of  the  Internal  Condyle  Obliquely  (Ogston*) 
(Fig.  199).  —  This  operation,  though  a  great  improvement  on  the 
operation  which  preceded  it — viz.,  opening  the  joint  and  sawing  off 
the  internal  condyle — has  been,  practically,  replaced  by  others — viz., 
Macewen's,  and  division  of  the  shaft  from  the  outer  side.  The  free 
opening  of  the  joint,  with  its  great  risks  if  the  wound  becomes  septic, 
and  the  stiffness  in  any  case,  have  led  to  this. 

The  limb  being  flexed,  and  supported  on  a  sand-bag,  a  long  teno- 
tome is  entered  about  an  inch  above  the  upper  border  of  the  articu- 
lar surface  of  the  femur  exactly  in  the  middle  of  the  inner  asi)ect  of 
the  thigh,  and  with  it  an  incision  is  made  down  to  the  bone,  down- 
wards and  forwards,  until  its  point  is  felt  beneath  the  skin  in  the 
inter-condyloid  notch. f  The  knife  must  cut  down  upon  the  bone  de- 
cidedly, and  as  it  is  withdrawn  it  must  enlarge  the  opening  for  the 
saw.  An  Adams's  saw  is  then  thrust  along  the  knife-track,  and  the 
inner  condyle  sawn  off  from  before  backwards.  The  bone  must  be 
sawn  almost  completely  through,  the  strokes  being  increasingly  care- 
ful as  the  back  of  the  bone  is  reached.  When  the  section  is  thought 
to  have  nearh'^  reached  this  point  the  saw  is  withdrawn,  the  wound 
covered  with  a  carbolized  sponge,  and  the  extended  leg  forced  strongly 
inwards.  The  condyle  now  slips  up  somewhat  on  the  cut  surface  of 
the  femur. 

IV.  Division  of  Tibia  as  well  as  Femur.— The  division  of  the 
tibia  (and  the  fibula  also)  as  well  as  the  femur  has  been  advocated  by 
Mr.  Barwell.  It  will  only  be  required.  Dr.  Macewen  thinks,  in  cases 
of  very  aggravated  genu  valgum,  for  these  reasons :  (1)  as  a  rule  the 
tibia  is  only  involved  to  such  a  slight  extent  that  osteotomy  of  the 
femur  is  alone  sufficient  to  straighten  the  limb.  (2)  Even  when  the 
tibia  is  markedly  involved  the  limb  can  be  sufficiently  straightened 
to  appear  quite  symmetrical  when  clothed.  (3)  The  amount  of 
straightening  brought  about  by  division  of  the  tibia  is  disappointing. 
The  same  is  the  case  when  the  fibula  is  also  divided.  Dr.  Macewen 
explains  this  by  the  mass  of  muscle  on  the  outer  and  back  part  of 
the  limb,  which  tends  to  bind  the  tibia  and  make  it  inflexible.  For 
the  above  reasons  Dr.  Macewen  has  abandoned  this  operation,  trust- 
ing to  division  of  the  femur  alone,  combined,  if  needful,  with  the 
division  of  the  biceps. 

*  Ellin.  Med.  Jour.,  March,  1877. 

t  If  tlie  piitella  is  sufficiently  dislocated  o\it\vards,  the  point  of  the  saw  can  be  felt 
in  the  groove;  but  if  the  patella  is  not  so  displaced,  it  must  be  lifted  up  and  the  point 
of  the  saw  passed  under  it. 


970  OPERATION'S    ON    THE    LOWER    EXTREMITY. 

Operation. — An  incision  is  made  in  the  soft  parts  over  the  inner 
surface  of  the  tibia  just  below  its  tubercle,  and  the  bone  divided  with 
osteotome  or  saw  from  within  outwards.  The  tissue  on  the  anterior 
part  just  below  the  tubercle  is  much  the  densest.  The  section  of  the 
tibia  should  be  made  on  the  same  occasion  as  that  of  the  femur.  Dr. 
Macewen  has  never  found  it  needful  to  operate  on  the  fibula. 

In  extremely  aggravated  cases,  multiple  osteotomies  will  be  required 
on  the  femur  and  the  tibia.  Thus  in  one  case  of  genu  varum,  in 
which  the  limbs  (when  the  ankles  were  placed  togther)  formed  a  circle, 
Dr.  Macewen  performed  ten  osteotomies  at  one  time  (loc.  supra  cit., 
Figs.  40  and  41).  However  an  osteotomy  wound  is  made,  whether 
witli  saw  or  chisel,  no  attempt  should  be  made  to  close  it,  but  a  little 
iodoform  dusted  on  and  dry-gauze  dressings  applied.  It  is  very  rarely 
needful  to  remove  these  before  the  tenth  or  fourteenth  day.  If  a  stain 
come  through,  it  should  be  dusted  with  iodoform  and  a  little  fresh 
dry  dressing  applied. 

Dr.  Macewen  uses  a  splint  consisting  of  a  long  outside,  a  short  back 
and  a  foot-piece.*  I  have  usually  preferred  plaster-of-Paris,  applied 
by  Mr.  Croft's  method,  for  children,  amongst  whom  my  experience 
has  mainly  laid.  It  makes  even,  steady  pressure  upon  the  muscles 
around  the  wound,  keeping  them  and  it  at  rest,  and  it  allows  the 
patient  to  be  more  easily  moved,  especially  when  both  limbs  have 
been  operated  on.  However  the  limb  is  put  up,  the  bandages  must 
be  applied  firmly  and  evenly,  but  without  undue  tightness.  The  con- 
dition of  the  toes,  as  to  color  and  movement,  must  be  carefully 
watched.  When  the  dressings  are  removed  at  the  end  of  ten  or  four- 
teen days  I  like  to  have  an  anaesthetic  given,  and  to  rectify  any  slight 
remaining  deformity  if  possible. 

The  splint  in  the  case  of  plaster-of-Paris  should  be  continued  for 
six  weeks,  when  the  limb  may  be  only  supported  with  sand-bags  if  the 
union  is  firm.  Passive  and  active  movement  may  be  now  allowed. 
In  about  another  fortnight  the  patient  may  be  got  up,  on  crutches, 
under  observation.  Before  the  patient  leaves  the  sugeon's  eye,  care 
should  be  taken  that  he  can  bend  his  knee  well. 

OSTEOTOMY  OF  TIBIA  (Fig.  199.) 

This  may  be  (A)  Simple  Division  or  (B)  Cuneiform — i.e.,  the 
taking  out  of  a  wedge  of  bone.  The  former  of  these,  a  very 
simple  operation,  will  suffice  for  the  ordinarily  curved  tibiae,  where 
the  bone  is  bent  laterally  and  the  bend  is  most  marked  at  the  junction 

*  Dr.  Macewen  advises  the  use  of  a  maUre-!s  consisting  of  four  parts,  the  two  centre 
pieces  corresponding  to  the  gliitseal  region,  and  easily  removed  to  admit  of  the  intro- 
duction of  the  bed-pan. 


OSTEOTOMY   OF   THE   TIBIA.  971 

of  the  middle  and  lower  thirds.    Cuneiform  osteotomy  Avill  be  required 
when  the  bending  is  not  onl}'  lateral,  but  antero-posterior  as  well. 

A.  Simple  Osteotomy  of  the  Tibia  (Fig.  199).— The  parts  being 
cleansed  and  the  limb  resting  on  its  outer  side  on  a  firm  sand-bag,  the 
surgeon  notes,  at  the  anterior  and  inner  margins  of  the  tibia,  the  spot 
where  the  curve  is  sharpest.  Fixing  his  left  index  over  the  inner 
margin,  he  enters  a  long  tenotome  or  narrow  bistour}"  exactly  over 
the  crest  of  the  tibia,  sends  it  down  under  the  skin  over  the  inner 
surfoce  of  the  bone  till  its  point  is  felt  just  beneath  the  finger;  it 
is  here  pushed  through  the  skin  to  make  a  counter-puncture  for 
drainage.  Tlie  knife,  hitherto  held  horizontally,  is  now  turned  ver- 
tically and  cuts  firmly  on  the  bone,  dividing  the  periosteum,  thick 
in  these  cases,  in  one  line  right  across  the  inner  surface  of  the  tibia. 
As  the  knife  is  withdrawn  it  is  made  to  enlarge  the  wound  of  en- 
trance slightly,  to  make  room  for  the  saw.  This  (Adams's)  is  now 
introduced  in  the  same  way  as  the  knife,  carried  horizontally  down 
to,  but  not  through,  the  puncture  through  the  skin  of  the  inner 
border  of  the  tibia.  The  left  index  keeping  guard  at  this  spot,  the 
saw  is  turned  towards  the  bone  and  cuts  through  the  inner  two-thirds 
of  it.  The  entrance  of  the  saw  into  cancellous  tissue  can  be  known 
by  the  diminution  of  resistance  and  the  increased  bleeding  which 
often  occur,  but  the  best  test  of  the  depth  to  which  the  operator 
has  arrived  is  the  depth  of  the  groove  in  which  the  saw  has  sunk. 
When  the  bone  is  sawn  sufficiently,  carbolized  lint  is  placed  on 
the  wound,  and  the  surgeon,  firmly  placing  his  two  hands,  close 
together,  immediately  above  and  below  the  wound,  sharply  carries  the 
lower  fragment  outwards.  If  the  saw  has  been  sufficiently  used,  the 
tibia  snaps  distinctly,  while  the  fibula*  yields  with  a  "  greenstick  " 
sensation.  Great  care  must  be  taken  to  exert  the  force  just  on  the 
sawn  portion,  or  the  ligaments  of  the  ankle  or  the  superior  tibio-fibular 
joint  may  be  strained  and  damaged.  Attention  has  already  been 
drawn  to  the  need  of  using  the  saw  sufficiently,  otherwise  the  parts 
will  be  bruised  and  damaged  in  the  futile  attempts  at  fracture. 

A  horsehair  drain  should  be  inserted,  a  little  iodoform  dusted  on, 
and  the  usual  dry-gauze  dressings  applied. 

B.  Cuneiform  Division  of  the  Tibia— Removal  of  a  Wedge. 
— The  parts  being  duly  cleansed,  an  incision  is  made  along  the  crest 
of  the  tibia  equal  to  the  base  of  the  wedge  which  is  going  to  be  removed. 
It  need  not  be  longer,  as  the  skin  can  be  pulled  up  and  down  if  need- 
ful. The  periosteum  is  then  divided  cleanly,  and  separated  from  the 
tibia  with  the  handle  of  the  scalpel  carbolized.  This  membrane  being- 
held  out  of  the  way  with  retractors,  a  wedge  is  next  removed  with  an 

*  In  many  of  my  earlier  cases  I  cut  down  upon  and  divided  this  bjoe,  a  step  not  at 
all  needful. 


972  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

osteotome  or  a  narrow  and  sharp  chisel  but  little  bevelled.  The  gap 
can  then  be  enlarged  by  removing  from  either  side  further  shavings  as 
required.  Occasionally  free  haemorrhage  takes  place  from  the  medul- 
lary artery,  but  this  soon  stops  with  firm  sponge  pressure.  The  limb 
is  now  straightened  by  bending  the  lower  fragment  upwards*  so  as  to 
bring  the  surfaces  of  the  gap  in  con-tact.  The  periosteum  at  the  upper 
and  lower  angles  of  the  wound  may  be  closed  with  chromic  catgut 
sutures  cut  short.  The  skin  wound  is  also  closed  above  and  below, 
but  left  ojien  in  the  centre  for  drainage.  Sufficiently  thick  dressings 
should  be  ap];)lie(l  to  meet  any  oozing  from  the  bone. 

OSTEOTOMY  FOR  DISPLACEMENT  OF  SMALL  TOE 

IN  BUNION. 

Mr..  Barker,,  at  the  suggestion  of  a  University  College  student,  has 
recommended  this  mode  of  correcting  the  inward  deformity  when  very 
troublesome  in  these  cases.  Antiseptic  osteotomy  of  the  first  phalanx 
or  metacarpal  bone  will  be  found  simpler,  and  thus  preferable,  to 
division  of  the  shortened  external  lateral  ligament,  and  any  tendons, 
such  as  the  extensor  longus  digitorum,  which  require  it.  In  bringing 
the  line  of  the  great  toe  straiglit  after  osteotomy,  care  must  be  taken 
not  to  do  this  too  rapidly,  or  the  contracted  skin  on  the  outer  side  of 
the  toe  may  give  way. 

Causes  of  Death  and  Failure  after  Osteotomy. 

1.  Septic  troubles.  Such  a  case  will  be  found  pul)lished  Clin.  Soc. 
Trans.,  vol.  xii.  p.  27.  It  is  too  probable  that  other  operators  have  not 
been  so  candid. 

2.  Carboluria.  A  case  of  rapidly  fatal  carbolic  intoxication  after 
antiseptic  osteotomy  of  the  tibia  will  be  found  in  the  same  Transactions, 
vol.  xiv.  p.  201. 

3.  Hsemorrhage.  At  least  one  case  has  occurred  of  haemorrhage 
from  the  femoral  and  one  from  the  anastomotica  after  division  of  the 
femur.  I  have  also  heard  of  one  in  which  the  posterior  tibial  was  in- 
jured in  osteotomy  of  the  tibia. 

4.  Necrosis.  This  occurred  in  one  of  my  cases  of  osteotomy  of  the 
femur,  a  lad  of  sixteen.  It  was  noticed  that  he  took  the  anesthetic 
(ether)  very  badly,  and  when  the  eff'ects  of  this  had  passed  off  he  was 
extremely  restless  and  excited  for  forty  minutes.  To  this  I  attribute 
the  mischief  that  followed.  Suppuration  with  a  very  unhealthy  state 
of  the  wound,  oedema,  and  cellulitis  ensued,  leading  to  necrosis. 
Eventually  the  lad  recovered,  but  required  a  cork  sole  of  2  inches. 
The  presence  of  a  presystolic  murmur  perhaps  accounted  for  the 
effects  of  the  ansesthetic. 

*  Aided  by  movements  in  the  opposite  direction,  and  from  side  to  side  if  needed. 
The  fibula  is  broken  subcutaneonslv. 


TENOTOMY.  973 

5.  Division  of  the  tibialis  anticus  tendon.  This  occurred  in  an  oste- 
otomy of  the  tibia  performed  by  one  of  my  dressers,  who  forgot  how 
close  the  tendon  lies  to  the  outer  side  of  the  crest.  The  cut  ends  were 
joined  by  chromic  catgut,  and  the  action «)f  the  muscle  was  miimpaired. 


CHAPTER  VIIL 
TENOTOMY, 


TENOTOMY  OF  THE  TENDONS  ABOUT  THE  FOOT.- 
SYNDESMOTOMY.— TENOTOMY  OF  HAMSTRING 
TENDONS,— TENOTOMY  OP  STERNO-MASTOID. 

TENOTOMY  OF  TENDONS  ABOUT  THE  FOOT. 

Division  of  Tibial  Tendons. 

Tibialis  Anticus. — This  is  usually  divided  where  it  is  crossing  the 
ankle-joint  from  without  inwards,  a  little  above  its  in^sertion  into  the 
internal  cuneiform.  It  has,  here,  the  anterior  tibial  vessels  on  its  outer 
side,  but  separated  from  it  by  the  extensor  proprius  pollicis. 

The  surgeon  usually  stands  on  the  opposite  side  of  the  leg  to  that 
of  the  tendon,  either  facing  the  trunk  or  with  his  back  towards  it,  as 
is  most  convenient.  The  assistant  stands  opposite  to  him,  grasping 
the  foot  with  one  hand  and  the  leg  with  the -other.  The  position  of  th* 
tendon  is  made  out  by  making  it  tense  by  abducting  and  extending  th<e 
foot.  The  surgeon  then  notes  the  position  of  the  anterior  tibial  vessels, 
defines  exactly  the  wi<lth  of  the  tendon,  and  places  the  tip  of  his  index 
finger  exactly  on  the  side  of  the  t&ndon  farthest  from  him.  He  then 
inserts  the  tenotomy  knife  vertically  close  to  the  tendon  on  the  side 
nearest  to  him ;  sinks  it  lightly  till  h^e  feels  sure  it  is  on  a  level  lower 
than  that  of  the  tendon;  then  sends  it  horizontally  across  till  he  feels 
its  point  just  uaider  his  index  finger,  and,  having  turned  its  edge  up- 
wards, finally,  by  a  series  of  light  levering  or  sawing  movements,  cuts 
through  the  tendom  The  assistant  relaxes  the  foot — i.e.,  adducts  and 
bends  it  upwards — when  the  knife  is  first  introduced,  but  places  it  on 
the  stretch  at  a  signal  from  the  surgeon.  Finall\%  as  soon  as  the  com- 
pletion of  the  creaking  sound  and  the  sudden  snap  denote  the  division 
of  the  tendon,  the  foot  is  again  relaxed.  A  small  pad  of  gauze  being 
at  once  applied,  the  foot  is  put  up  in  the  everted  position.  For  this 
purpose  nothing  is,  to  my  mind,  so  simple  and  efficient  as  a  well- 
padded  splint  of  the  proper  width,  with  two  notches  at  its  lower  end, 
the  upper  end  being  just  below  the  knee  in  infants,  and  thelosver  2:»ro- 
jecting  2-i  inches  below  the  foot     The  splint  is  applied  to  the  outer 


974  OPERATIONS    ON   THE    LOWER    EXTREMITY. 

side,  the  leg  being  first  rolled  in  a  flannel  bandage  to  prevent  pressure- 
sores. 

Tibialis  Posticus. — It  is  usually  recommended  to  divide  this  Ih 
or  2  inches  above  the  internal  malleolus.^  The  tendon  is  here  sepa- 
rated from  the  posterior  tibial  vessels  by  the  flexor  longus  digitorum. 

The  surgeon  and  his  assistant,  occupying  positions  as  at  p.  973, 
the  exact  site  of  the  tendon  is  defined,  if  possible,  by  abducting  and 
bending  down  the  foot.  In  fat  infants  it  is  often  quite  impossible  to 
feel  the  tendon,  and  in  these  cases  a  spot  midway  between  the  anterior 
and  posterior  borders  of  the  leg  will  be  the  best  guide,  as  denoting 
the  inner  margin  of  the  tibia.  The  surgeon  then  introduces  a  sharp 
tenotome  so  as  just  to  touch,  if  possible,  the  inner  margin  of  the  tibia, 
taking  care  to  sink  the  blade  sufficiently  to  open  the  sheath  freely. 
This  being  done,  a  blunt  tenotome  is  introduced  through  the  same 
opening,  and  pushed  under  the  tendon ;  the  edge  being  then  turned 
towards  it,  and  the  tibia  used  as  a  fulcrum,  the  tendon  is  severed, 
together  with  that  of  the  flexor  longus  digitorum.  The  assistant  first 
relaxes  and  then  extends  the  tendon,  as  advised  above  (p.  973). 

If  the  artery  be  cut,  as  shown  b}^  the  jetting  ha3morrhage  and  the 
blanching  of  the  foot,  firm  pressure  must  be  applied,  the  foot  being 
first  bandaged.  No  eversion  must  be  practiced  but  the  foot  put  up  in 
the  faulty  position  for  about  a  Aveek. 

Plantar  Fascia.f — This  may  be  divided  just  below  its  origin  from 
the  OS  calcis,  or  in  advanced  cases  close  to  the  transverse  crease,  which 
is  here  found  in  the  sole.  With  regard  to  this  fascia,  the  surgeon 
should  not  tie  himself  down  to  any  fixed  spot,  but  divide  resisting 
bands  wherever  they  are  felt. 

Syndesmotomy. — This  term  has  been  introduced  by  Mr.  R.  W. 
Parker,!  who  believes  that  in  many  cases — e.g.,  severe  ones,  cases  not 
treated  in  early  life,  and  in  some  relapsed  cases — the  foot  cannot  be 
rectified  even  by  multiple  tenotomy.  He  attributes  this,  not  to  adhe- 
sions, but  to  the  faulty  shortness,  and  unyielding  nature  of  the  liga- 
ments. Chief  amongst  these,  in  equino-varus,  are  the  ligaments  about 
the  astragalo  scaphoid  joint.  "  In  these  cases  there  is  a  capsule  made 
up  above  and  internally  by  a  blending  together  of  the  superior  astra- 
galo-scaphoid  ligament  with  filjres  from  the  anterior  ligament,  and 
the  anterior  portion  of  the  deltoid  ligament  below  with  fibres  from  the 
inferior  calcaneo-scaphoid  ligament.  To  these  are  united  fibrous 
expansions  of  the  tendons,  of  the  anterior  and  posterior  tibial  muscles  ; 

*  The  tendon  is  here  rather  fartlier  from  tlie  artery,  and  the  surgeon  will  be  above 
the  commencement  of  its  synovial  sheath,  in  which  it  traverses  the  internal  annular 
ligament. 

f  Division  of  the  palmar  fascia  is  fully  described  at  p.  32. 

X  Congenital  Club-footy  p.  62  el  passim. 


TENOTOMY.  975 

together  they  form  an  unyielding  capsule  of  great  strength,  which  is 
attached  to  the  several  bones,  not  in  the  usual  manner,  but  in  adap- 
tation to  their  altered  relative  positions.  This  I  would  name  the 
*  astragalo-scaphoid  capsule.'  "  Mr.  Parker  gives  directions  for  divid- 
ing this  structure  which  can  be  made  to  combine  division  of  the  tibial 
tendons  in  a  manner  which  I  consider  far  more  satisfactory  than  that 
already  given.  Since  reading  his  book  I  have  adopted  his  method 
in  nine  cases  with  good  results.  I  much  prefer  it  to  that  usually 
followed. 

The  site  chosen  for  this  combined  division  of  tendons  and  ligaments 
is  a  little  below  and  anterior  to  the  tip  of  the  internal  malleolus.* 
Other  guides  are  the  site  of  the  astragalo-scaphoid  joint,  and  in 
advanced  cases  the  transverse  crease  which,  running  down  on  to  the 
sole,  denotes  the  inversion  of  the  foot.  Two  tenotomes  are  required, 
one  of  ordinary  pattern,  and  one  curved,  somewhat  sickle-shaped, 
and  with  a  cutting  blade  about  2  inch  in  length. 

The  surgeon  notes  the  position  of  the  tibial  arteries,  and  the  lines 
along  which  the  tibial  tendons  are  curving  towards  the  internal  cunei- 
form. Having  marked  at  the  spot  above  given  the  position  of  these 
tendons,  he  enters  a  sharp-pointed  tenotome,  the  parts  being  relaxed, 
just  above  the  posterior  tibial  artery,  and  pushes  it  inwards  on  to  the 
dorsum  to  a  spot  just  short  of  the  anterior  tibial  artery,  the  knife  being 
entered  just  below  the  skin  to  make  a  path  for  the  next  instrument, 
which  does  the  work.  The  curved  tenotome  is  then  inserted  under 
the  skin,  and  pushed  on,  flat  wise,  till  its  tip  can  be  felt  over  the 
tibialis  anticus ;  it  is  then  turned  blade  downwards,  the  tibialis 
anticus  is  felt  to  give  way,  and,  as  the  knife  cuts  on  the  subjacent 
bones  and  cartilages,  the  ligaments  are  felt  to  yield  to  it,  Avhile,  as  it 
is  withdrawn,  its  edge  divides  the  tibialis  posticus. 

The  internal  saphena  vein  would  seem  to  lie  under  this  incision, 
but  the  haemorrhage,  never  marked,  is  usually  very  slight.  As  I  have 
stated,  the  results  in  the  nine  cases  in  which  I  have  used  this  method 
have  been  excellent,  though  in  two  I  was  unable  to  satisfy  myself  that 
the  tibialis  posticus  had  given  way ;  in  one  it  was  certainly  notched, 
and  yielded  subsequently. 

As  in  this  method  the  incision  is  made  from  the  skin  down  upon 
the  tarsal  bones,  I  have  used  the  spray  or  irrigation  with  lotion  of 
mercury  pei'chloride  or  carbolic  acid.  The  wound  is  a  comparatively 
free  one,  but  quite  subcutaneous,  starting  from  a  mere  puncture. 

As  I  have  stated,  I  prefer  to  put  up  a  case  of  talipes  varus  after 
syndesmotomy,  with  the  foot  everted  at  once,  on  a  notched  splint  like 

*  Mr.  Parker  {loc.  supra  cit ,  p.  78)  shows  that  Velpeaii  and  Syme  pointed  out  the 
possibility  of  dividing  tlie  tendon  of  the  tibialis  posticus  here. 


976  OPERATIONS    ON    THE    LOWER    EXTREMITY. 

a  Dupiiytren's,  but  applied  to  the  outer  side.  If  the  tendo-Achillis 
requires  division,  this  is  done  in  a  few  days,  and  the  foot  put  up  for 
about  a  week,  in  good  position,  by  Mr.  Croft's  method  of  plaster-of- 
Paris.  After  this,  in  early  life,  the  foot  must  be  manipulated  daihj 
by  the  surgeon  for  a  while,  and  later  by  the  friends,  the  surgeon  seeing 
it  at  first  every  other  day.  If  these  manipulations  are  persevered 
with  daily  by  the  mother  or  nurse,  and  the  case  kept  under  the 
surgeon's  eye,  expensive  boots  and  other  apparatus  will  not  be  needed 
in  children. 

Tendo-Achillis. — This  should  be  divided  about  an  inch  above  its 
insertion,  its  narrowest  part.  The  surgeon  stands  inside  the  right, 
outside  the  left,  foot,  with  his  back  turned  towards  the  body  in  the 
former,  and  facing  it  in  the  latter  case.  The  assistant  stands  opposite 
to  him,  grasping  the  foot  as  before. 

The  foot  and  leg  being  turned  well  over  on  to  the  outer  side,  and 
the  tendon  being  relaxed  by  bending  the  foot  downwards,  the  margins 
of  the  tendon  are  accurately  defined.  The  knife  is  then  introduced 
vertically  close*  to  the  inner  side  of  the  tendon  till  it  reaches  a  suffi- 
cient depth  to  ensure  being  beneath  it;t  it  is  then  pushed  horizontally 
across  under  the  tendon  till  it  is  felt  under  the  skin  by  the  left  index 
finger,  which  accurately  marks  out  the  outer  limit  of  the  tendon  ;  the 
blade  is  then  turned  towards  the  tendon,  which,  being  put  on  the 
stretch  by  bending  up  the  foot,  is  divided  by  a  series  of  levering 
movements  of  the  handle.  Creaking  movements,  followed  by  a 
sudden  snap  or  thud,  denote  complete  division,  when  the  tendon  is 
to  be  at  once  relaxed  and  the  knife  brought  out  horizontally. 

The  Peronsei. — The  perona?us  longus  et  brevis  occasionally  require 
division.  They  may  be  divided  simultaneously  by  entering  a  teno- 
tome between  them  and  the  bone  about  an  inch  above  the  external 
malleolus.  Immediately  above  this  process  they  are  more  under 
cover  of  the  bone.  If  divided  below  it,  their  synovial  sheath  would 
be  opened,  a  result  requiring  greater  care  in  cleanliness. 

TENOTOMY  OF  THE  HAMSTRINGS. 

The  patient  being  rolled  two-thirds  on  to  his  ftice,  the  surgeon 
stands  on  the  same  side  as  that  on  which  lies  the  tendon  to  be 
divided,  facing  or  turned  from  the  trunk  as  is  most  convenient.  An 
assistant  stands  opposite  to  him  to  relax  and  tighten  the  tendon. 

Biceps. — The  exact  limits  of  the  tendon  being  defined,  the  surgeon 

*  So  as  to  avoid  the  posterior  tibial  artery. 

f  Young  operators  often  do  not  insert  tlie  knife  sufficiently  deep;  tliey  tiuis,  when 
it  is  pushed  across,  get  into  the  tendon  instead  of  beneath  it,  and  so  divide  it  incom- 
pletely. 


TENOTOMY.  977 

introduces  a  sharp  knife  close  to  the  inner  side  of  the  biceps,  so  as  to 
get  between  it  and  the  external  poplitseal  nerve,  and,  having  sunk  it 
sufficiently  to  get  beneath  the  tendon,  pushes  the  knife  outwards, 
horizontally,  till  it  is  felt  beneath  the  skin  under  the  left  index, 
Avhich  marks  the  outer  limit  of  the  tendon.  The  edge  being  turned 
towards  this,  the  tendon  is  extended  by  the  assistant,  and  divided  in 
the  usual  way.  When  this  is  done,  the  limb  is  flexed  and  the  knife 
withdrawn  horizontally. 

When  the  tendon  is  cut,  a  cord  often  rises  up  close  to  it.  This  is 
the  nerve,  and  the  knife  must  on  no  account  be  re-introduced. 

If,  after  tenotomy  in  long  standing  cases,  any  contracted  bands  of 
f;5scia  do  not  give  way  to  extension,  which  they  will  generally  do,  it  is 
wiser  to  make  a  small  open  wound,  antiseptically,  and  divide  them 
thus,  that  the  surgeon  may  be  certain  as  to  what  he  is  dividing.  The 
wound  is  united  afterwards  with  one  or  two  horse-hair  sutures. 

Semi-tendinosus  and  Semi-menibranosus. — These  tendons 
can  be  divided  in  the  same  way  as  the  biceps.  A  contracted  knee 
can  generally  be  straightened  after  division  of  the  biceps  and  semi- 
tendinosus.  If  it  is  needful  to  insert  the  knife  more  deeply  so  as  to 
divide  the  semi-membranosus,  it  would  be  well  to  use  a  blunt-pointed 
tenotome.^  In  one  case  of  a  girl  of  sixteen,  after  I  had  divided  the 
biceps  and  semi-tendinosus,  I  had  dipped  the  point  of  the  knife  a  little 
more  to  ensure  division  of  the  deeper  and  larger  semi-membranosus. 
Most  profuse  haemorrhage  followed  from  the  superior  internal  articular 
vessels.  Firm  padding  and  bandaging  were  applied,  and  the  limb 
put  up  in  the  faulty  position  for  four  days.  No  recurrence  of  the 
bleeding  took  place. 

TENOTOMY  OP  THE  STERNO-MASTOID. 

The  two  heads  are  best  divided  from  separate  punctures  just  above 
the  clavicle.  The  muscle  being  made  prominent  by  one  assistant 
manipulating  the  head  and  another  depressing  the  shoulder,  the  sur- 
geon, standing  facing  the  patient  on  the  side  to  be  operated  upon, 
defines  the  limits  of  the  inner  border  of  the  sternal  tendon,  opens  the 
fasciae  sufficiently  freely  here,  and  then,  taking  a  blunt-pointed  teno- 
tome, insinuates  it  horizontally  behind  and  close  to  the  tendon  till  it 
is  felt  just  beneath  his  left  index  finger,  which  is  placed  at  the  outer 
margin ;  the  edge  is  then  turned  towards  the  tendon,  and  divides  it. 
It  is  withdrawn  with  the  usual  precautions.  The  clavicular  tendon 
is  divided  in  a  similar  way  through  another  puncture. 

Care  must  be  taken  to  avoid  the  anterior  jugular,  which  runs  out- 


*  Mefssrs.  Smith  and  Walsham  and  Mr.  Barker  {Mans,  nf  Oper.  Surg.)  recommend 
this  course  for  inner  and  outer  hamstrings  alike. 

62 


978  OPERATIONS    ON    NERVES. 

wards  under  the  muscle  a  little  above  the  clavicle,  and  the  external 
jugular,  which  lies  at  a  varying  level  close  to  the  outer  border  of  the 
clavicular  head.  If  a  sharp  tenotome  be  dipped  too  deeply,  the 
internal  jugular  might  also  be  wounded. 

If  any  smart  venous  hemorrhage  occur,  a  pad  of  dry  gauze  should 
be  firmly  bandaged  on. 

Another  method  is  given  by  some  surgeons*  of  passing  a  director 
beneath  the  heads  of  the  muscle  and  dividing  them  on  it  with  a  narrow 
bistoury  or  tenotome. 

Causes  of  Failure  after  Tenotomy. 

1.  Septic  troubles.  These  usually  arise  from  the  use  of  dirty 
instruments  which  clean  themselves  at  the  patient's  expense,  or  from 
making  an  open  wound. 

2.  Incomplete  division  of  the  tendon. 

3.  Division  of  important  structures — e.g.^  the  tibial  arteries,  the 
external  popliteal  nerve,  the  anterior  or  internal  jugular  veins. 

4.  Non-union  of  the-  tendon. 

5.  Mal'Union  of  the  tendon — i.e.,  adhesions  formed  by  it  to  adjacent 
structures,,  e.g.,  its  sheath  or  a  bone.  These  must  both  be  extremely 
rare. 

6.  Breaking  off  the  point  of  the  tenotome,  usually  against  a  bone. 


CHAPTER   IX. 
OPERATIONS  ON  NERVES. 

NERVE  SUTURE.-NERVE.  STRETOHING. 

NERVE  SUTURE. 

This  may  be  required  as  a  primary  or  secondary  operation. 
The  latter  is  accompanied*with  much  more  difficulty,  owing  to  the 
greater  retraction  of  the  nerve  ends,  their  bulbous  or  filiform  extremi- 
ties, their  being  often  buried  in  scar  tissue  or  matted  by  it  to  neigh- 
boring parts — e.g.,  tendons  and  fasciae;  to  which  must  be  added  other 
unfavorable  points — e.g.,  the  atrophy  and  fatty  change  in  the  muscles 
and  the  stiflFness  of  the  joints. 

Primary  Suture. — As  the  mode  of  uniting  nerves  will  be  fully 
described  under  the  head  of  secondary  nerve  suture,  the  more  difficult 
proceeding,  it  need  not  be  repeated  here.  It  only  remains  to  empha- 
size the  importance  of  always  resorting  to  it,  and  not  trusting  to 

*  Smith  and  Walsham,  Man.  of  Oper.  Surg.,  p.  29  ;  Barker,  Man.  of  Oper.  Surg.,  p.  74. 


NERVE   SUTURE.  979 

spontaneous  cure.  As  an  instance  of  what  maybe  done  in  very  severe 
cases  I  may  mention  the  following  case  :*  A  woman  of  suicidal  ten- 
dency wounded  herself  above  both  wrists.  On  the  right  side,  the  radial, 
ulnar,  and  anterior  interosseous  arteries  were  divided,  the  radial  and 
median  nerves  completely,  and  the  ulnar  almost  completely.  Appar- 
ently all  the  tendons  were  severed  also.  On  the  left  side,  the  radial 
and  ulnar  arteries  w^ere  divided,  the  radial  and  ulnar  nerves  completely, 
and  the  median  nerve  almost  cut  through.  The  superficial  tendons 
were  quite,  the  deep  partly,  severed.  The  nerves  and  tendons  were 
sutured.  Three  weeks  later  sensation  was  perfectly  normal  and  active, 
and  passive  movement  was  begun. 

Secondary  Suture. — The  operation  on  the  median  or  ulnar  will 
be  considered,  as  these  are  so  commonly  injured.  The  following  steps 
must  be  remembered  :  (1)  Finding  the  nerve  ends.  (2)  Freeing  and 
refreshing  them.  (3)  Passing  the  sutures,  and  bringing  the  ends  into 
apposition.     (4)  Dressing  the  wound,  and  the  after-treatment. 

1.  Finding  the  Nerve  Ends. — With  accurate  anatomical  knowledge 
this  is  easy.  An  Esmarch's  bandage  does  not  appear  to  be  necessary, 
as  the  incision  is  made  parallel  with  the  vessels,  and  the  use  of  one 
leads  to  oozing  afterwards.f  If  bandages  are  employed,  the  parts 
should  be  made  absolutely  evascular ;  careless  application  will  only 
cause  most  annoying  oozing.  An  incision,  2  to  3  inches  long,  being 
made  over  and  parallel  to  the  nerve  ends,  the  deep  fascia  and  any 
scar  tissue  are  carefully  divided  and  the  ends  found,  the  upper  bulb- 
ous and  the  lower  filamentous  usually ,:[:  and  not  always  in  a  line  with 
each  other.     They  are  next  freed  from  the  adjacent  parts. 

2.  Resection  of  the  Nerve  Ends. — This  is  best  eff'ected  by  sharp  scissors, 
with  one  stroke,  and  without  any  bruising.  If  the  nerve  is  held  with 
forceps,  these  must  hold  the  sheath  only.  In  case  of  primary  suture, 
jagged  or  frayed  ends  need  only  be  pared  sufficiently.  In  later  cases 
there  is  much  more  difficulty.  Supposing  the  upper  bulbous  end  to 
be  taken  first,  I  think  that  before  this  is  pared  the  nerve  should  be 
carefully  stretched,§  so  that  dissecting-forceps  or  any  other  means  of 

*  Land.  Med.  Record,  1881,  p.  152;  Kraussould,  Centr.f.  Chir.,  1880,  No.  47. 

t  Mr.  Bowlby,  in  his  Hiinterian  Lectures  {Lancet,  July  16,  1887),  thinks  that  the 
parts  should  be  rendered  bloodless.  If  this  course  is  adopted  care  must  be  taken  to 
provide  sufficient  drainage,  and  the  upper  bandage  must,  if  possible,  be  applied  suffi- 
ciently far  from  the  wound  not  to  interfere  with  pressing  down  the  parts  wlien  the 
nerve  ends  are  approximated. 

X  If  the  distal  end  be  very  difficult  to  find  owing  to  its  filiform  shape  and  its  being 
embedded  in  scar  tissue,  the  wound  should  be  prolonged,  tlie  nerve  found  lower  down, 
and  traced  up  to  the  distal  end. 

§  An  Esmarch's  bandage,  if  applied,  will  be  found  in  the  way  now,  interfering,  as 
it  usually  must,  with  the  stretching  of  the  nerve. 


980  OPERATIONS   ON    NERVES. 

holding  the  nerve  may  inflict  any  necessary  damage  on  parts  that  will 
be  cut  away.  It  is  not  necessary  to  cut  away  the  whole  of  a  bulb ; 
removing  the  greater  part  will  expose  healthy  nerve  fibres.  Mr. 
Bowlby  {loc.  supra  cit.)  advises  that  the  section  of  the  upper  end  should 
be  carried  through  the  uppermost  part  of  the  bulb,  close  to  the  normal 
trunk.  Not  only  will  numerous  young  fibres  be  found  here,  but,  as 
he  points  out,  the  tougher  tissue  of  the  bulb  affords  an  excellent  hold 
for  the  sutures.  With  regard  to  the  lower  end,  Mr.  Bowlby  thinks 
that  all  that  is  needed  is  "  to  cut  away  the  extreme  end,  which,  being 
matted  with  fibrous  tissue  and  compressed  by  the  surrounding  scar, 
is  very  likely  to  contain  no  nerve  tubules.  It  is  seldom  necessary  to 
remove  as  much  as  4  inch,  and,  however  unhealthy  the  section  may 
look,  no  good  is  ever  to  be  gained  by  a  further  sacrifice."* 

3.  Passing  the  Sutures  and  bringing  the  Nerve  Ends  in  Apposition. — The 
sutures  should  be  of  properly  prepared  carbolized  silk  or  chromic  gut. 
There  has  been  much  dispute  as  to  whether  they  should  be  passed 
through  the  substance  of  the  nerve  itself  or  only  through  the  sheath. 
Experience  has  shown  that  the  former  practice  is  not  only  harmless 
to  the  nerve,  but  is  the  method  most  generally  applicable.  In  a  few 
cases,  as  in  that  of  a  large  nerve,  where  there  is  but  little  separation, 
and  where  the  damage  is  just  inflicted,  it  may  be  sufficient  to  pass 
the  sutures  through  the  sheath  only.  But  in  the  opposite  class  of 
cases  the  suture  should  be  passed  through  the  nerve  itself,  and  at  a 
sufficient  distance  from  the  ends — viz.,  at  least  4  inch — otherwise  when 
they  are  tightened  they  will  cut  out.  Where  there  is  much  separa- 
tion, several  sutures  should  be  passed  through  part  of  the  depth  of 
the  nerve,  one  suture  thus  taking  off  some  of  the  tension  from  its 
fellows.  Another  method  is  to  pass  one  suture  completely  through 
the  nerve  trunk  at  least  J  inch  from  each  cut  end.  When  the  sutures 
in  the  nerve  itself  have  been  tied,  two  or  three  more  very  fine  ones 
may  be  placed  in  the  sheath,  where  the  nerve  is  large  enough.f 

In  cases  of  much  separation,  before  any  sutures  are  passed,  and 
again  before  they  are  tied,  the  parts  should  be  as  much  relaxed  as 
possible,  and  the  upper  end  brought  down  by  pressing  down  the  soft 
parts.     Stretching  the  nerve  has  been  already  advised  (p.  979). J 

*  As  the  whole  length  of  the  lower  end  is  in  the  same  condition  of  degeneration  or 
regeneration  throughout,  manifestly  no  good  can  be  done  by  cutting  off  successive 
sections  in  the  hope  that  the  cut  surface  may  look  more  healthy  than  that  which  is 
seen  in  the  first  resection  (Bowlby). 

t  To  prevent  the  adhesion  of  the  recently  united  ends  to  neighboring  parts,  short 
strands  of  catgut  may  be  placed  beneath  them,  but  this  is  not  essential. 

X  In  cases  where,  in  spite  of  ail  precautions,  much  tension  is  evidently  left  on  the 
sutures,  it  might  be  well  to  make  use  of  "stitches  of  fixation,"  as  in  tendon  suture 
(p.  39). 


NERVE  SUTURE.  981 

All  hemorrhage  being  scrupulously  arrested,  and  drainage  provided 
by  horsehair  or  a-  fine  tube  according  to  the  amount  of  the  disturb- 
ance of  the  parts,  etc.,  dry- gauze  dressings  are  applied,  and  the  limb 
placed  on  a  well-padded  splint  in  a  position  which  will  best  retain 
the  nerve  ends  in  apposition  with  the  least  discomfort  to  the  patient. 

Amount  of  Nerve  Tissue  which  may  be  Successfully  Removed. — From  \ 
to  4  inch  is  probably  an  average  amount. 

Causes  of  Failure. 

1.  Wide  separation  of  ends. 

2.  Atrophy,  bulbous  enlargement  and  sclerosis  of  nerve  ends,  so 
marked  as  to  require  much  trimming,  and  thus  tending  to  wide 
separation. 

3.  Unnecessarily  rough  handling  of  the  nerve  ends. 

4.  Suppuration  of  the  wound. 
Aids  in  DifBcult  Cases. 

1.  Previous  stretching  of  the  ends. 

2.  Approximation  of  the  ends  by  position  of  the  limb. 

3.  Using  several  sutures,  which  distribute  the  tension  evenly. 

4.  Perhaps  cutting  splices,  and  so  joining  widely  separated  ends. 
The  remaining  methods  must  be  looked  upon,  as  yet,  as  exi^eri- 

mental  only. 

5.  Autoplastic  operation  with  nerve-flaps.  M.  Letievant  advises  to 
make  a  slit  through  the  nerve  with  a  narrow  bistoury,  about  \  inch 
from  the  end  ;  the  knife  being  then  carried  upwards  for  1  or  1?  inch, 
it  is  made  to  cut  to  one  side,  so  as  to  make  a  flap.  The  same  is  then 
done  with  the  lower  end,  and  the  two  flaps,  being  turned  towards 
each  other,  are  united  by  their  raw  surfaces. 

6.  Gluck  and  Vanlair  advise  that  the  nerve  ends,  whether  united  or 
only  placed  as  closely  as  possible  in  apposition,  should  be  passed 
through  and  left  in  a  decalcified  bone-tube,  so  as  to  keep  the  uniting 
material  and  granulations  in  a  straight  line. 

7.  Engrafting  one  nerve  upon  another.  Thus,  where  the  ulnar  is 
too  widely  destroyed  to  bring  the  ends  together,  ihe  distal  end,  frayed 
out,  has  been  stitched  to  the  median,  the  sheath  and  superficial  fibres 
of  this  having  been  first  removed.  The  success  seems  to  have  been 
slight  and  partial. 

8.  Gluck  has  resected  1^  inch  of  the  great  sciatic  in  chickens,  and 
replaced  it  by  a  bit  of  a  rabbit's  sciatic  sutured  in.  The  birds  walked 
afterwards  as  well  as  those  treated  by  direct  suture,  while  nerve 
resection  without  suture  was  followed  by  paralysis  complete  at  the 
end  of  ten  weeks. 

Period  Required  for  Repair. — The  following  appears  to  be  a  fact  not 
sufficiently  recognized.  The  jjeriod  required  for  union  after  sec- 
ondary nerve  suture  is  very  much  longer  than  is  usually  supposed 


982  OPERATIONS    ON    NERVES. 

to  bo  necessary,  owing  to  the  peripheral  end  being  degenerated,  the 
muscles  atrophied,  and  the  joints  fixed.  Complete  restoration  of 
function  will  often  require  from  one  to  two  years.  A  patient  who 
leaves  his  surgeon  apparently  but  little  better  for  tlie  operation  may 
return  at  the  end  of  the  above  time  with  his  limb  practically  restored 
to  its  natural  condition.* 

It  is  the  above  condition  of  the  muscles  and  joints  which  alone  puts 
anything  like  a  limit  on  the  period  at  which  secondary  suture  can  be 
successfully  practiced. 

The  longer  the  intervalf  between  the  injury  and  the  suture,  the 
more  perseveringly  must  friction,  electricity,  passive  and  active  move- 
ment, and  massage  be  made  use  of,  and  the  more  will  patience  be 
required  by  both  patient  and  surgeon. 

NERVE  STRETCHING. 

This  operation,  introduced  into  England  in  1880,  and  much  used 
in  the  immediately  succeeding  years,  has  lately  fallen  into  abeyance, 
the  clinical  results  having  failed  to  come  up  to  the  expectations  raised 
by  the  operation. 

Indications. — Of  the  following  list  it  is  only  in  the  first  six  that 
the  operation  can  be  considered  justifiable. 

1.  Neuralgise.  In  all  cases  where  previous  treatment  has  failed, 
nerve  stretching  may  be  practiced  before  division  of  or  removal  of 
part  of  a  nerve. J  The  conditions  justifying  this  in  facial  neuralgia 
have  been  already  given  (p.  235).  As,  however,  the  results  of  neurec- 
tomy for  facial  neuralgia  are  far  superior  to  those  of  nerve  stretching, 
the  latter  is  only  to  be  recommended  on  the  ground  that,  owing  to 
the  inveteracy  of  the  disease,  recurrence  is  only  too  probable  even 
after  neurectomy,  and  thus  a  previous  nerve  stretching  may  give  a 
further  period  of  relief. 

2.  Sciatica.  Nerve  stretching  is  especially  indicated  here  in  cases 
due  to  rheumatic  inflammation  of  the  nerve  from  exposure  to  cold 
and  wet.§  The  more  definite  is  the  sensation  of  adhesions  broken 
down  at  the  time  of  the  operation,  the  better  is  the  prognosis. 


*  Mr.  Bowlby  {loc.  supra  cit.)  writes:  "If  there  is  one  fact  more  than  another  which 
stands  out  in  the  clinical  histories  of  patients  who  have  been  under  my  own  observa- 
tion, it  is  that  after  the  failure  of  union  by  first  intention,  after  tropliic  changes  of 
many  kinds,  after  complete  atrophy  and  degeneration  of  the  paralyzed  muscles, 
recovery  may  yet  be  complete." 

t  The  longest  of  these  with  which  I  am  acquainted  is  a  case  of  M.  Tillaux's,  in 
which  fourteen  years  had  elapsed  between  the  injury  to  the  median  and  its  suture. 

X  See  a  paper  by  Mr.  Walsham  {Brit.  Med.  Journ.,  December,  1880),  in  which  the 
possible  causes  of  relief  after  nerve  stretciiing  for  neuralgia  are  discussed. 

§  Dr.  J.  P.  Bramwell  has  published  {Brit  Med.  Journ.,  June  19,  1880)  five  cases 
of  this  kind,  in  which  much  benefit  followed  stretciiing  the  great  sciatic. 


NERVE   STRETCHING.  983 

3.  Locomotor  ataxy.  One  or  both  great  sciatics  have  been  stretched 
with  a  view  of  improving  the  lightning  pains,  the  involuntary  jerkings 
of  the  lower  limbs,  and  the  gait*  While  improvement  for  a  var3'ing 
period  may  always  be  expected  as  ftir  as  the  first  two  are  concerned, 
the  prospect  of  improving  the  ataxy  is  very  doubtful.  Furthermore 
the  slow  healing  of  the  wound  in  these  cases  must  be  borne  in  mind. 

4.  Spasmodic  contractions  of  voluntary  muscles.  Here  the  operation 
seems  to  have  been  followed  by  success,  temporary  at  least,  in  a  very 
large  number  of  cases.  Where  the  spasmodic  affection  is  of  traumatic 
origin — e.g.,  where  a  limb,  after  a  contusion,  is  at  the  same  time 
contracted  and  the  seat  of  spasmodic  movements — stretching  of  the 
nerves  concerned  may  be  absolutely  curative.  Quite  another  class  of 
cases — viz.,  stretching  the  facial  for  tic  eonvulsif — has  been  considered 
at  p.  237. 

5.  Reflex  epilepsy.  Prof.  Horsley  {Did.  of  Surg.,  vol.  ii.  p.  61) 
states  that,  in  those  cases  of  epilepsy  where  the  attack  is  preceded  by 
violent  pains  localized  distinctly  to  different  nerves,  very  marked 
relief  (amounting  to  cure  in  several  instances)  has  been  obtained  by 
stretching  the  nerve-trunks  thus  indicated. 

6.  AnaBsthesia  of  leprosy.  Lawrie,  of  Lahore,  seems  to  have  met 
with  striking  success,  the  fifty  cases  published  being  all  successful. 

In  the  remaining  conditions  nerve  stretching  is  of  more  than 
doubtful  benefit. 

7.  Tetanus.  Owing  to  the  fatality  of  traumatic  tetanus,  nerve 
stretching  may  be  tried  here  if  the  case  is  seen  at  a  very  early  stage 
of  the  disease.  But  owing  to  our  ignorance  of  the  pathology  of  the 
disease,  especially  with  regard  to  the  date  at  which  the  spinal  cord  is 
aflfected,  and  from  the  difficulty  of  making  sure  of  stretching  all  the 
nerves  involved,  this  treatment  cannot  be  looked  upon  as  hopeful. f 

8.  Infantile  paralysis.  Prof.  Horsley  (loc.  supra  cit)  states  that  in 
1881  Dr.  Bastian  had  the  great  sciatic  nerve  stretched  to  improve  the 
nutrition  in  a  limb  the  seat  of  the  above  disease.  The  effect  was  to 
markedly  increase  the  temperature  and  color  of  the  part,  and  ap- 
parently improve  the  state  of  the  tissues.  The  result,  however,  does 
not  seem  to  have  been  such  as  to  find  imitators. 

*  In  a  case  of  Dr.  Bastian's  (Brit.  Med.  Journ.,  July  2,  1881),  the  patient,  in  an 
advanced  stage  of  ataxy,  experienced  so  much  relief  from  the  stretching  of  one  great 
sciatic,  tiiat  he  asked  for  an  operation  on  the  other  side.  An  interesting  paper  by 
Dr.  Cavafy,  witii  nineteen  cases  collected  from  different  sources,  will  be  found  in  the 
Brit.  Med.  Journ.,  1881,  pp.  928,  973. 

f  Mr.  PI.  Morris  points  out  {Brit.  Med.  /own.,  January  14,  1882)  that  in  one  case 
of  acute  tetanus  claimed  to  be  cured  by  nerve  stretching,  the  medicinal  treatment 
adopted  (Calabar  bean)  was  too  active  to  permit  of  any  conclusion  in  favor  of  the 
operation. 


984  OPERATIONS   OX   NERVES. 

Operation  (Fig.  95).— The  following  remarks  refer  to  the  great 
sciatic  only,  the  nerve  which  has  been  most  frequently  stretched. 

*  The  parts  being  cleansed,  an  incision  about  4  inches  long  is  made 
over  the  nerve  in  the  centre  of  the  back  of  the  thigh,  commencing 
about  U  inches  below  the  lower  border  of  the  gluta3us  maximus. 
The  interval  between  the  hamstrings  being  hit  off,  retractors  are  in- 
serted, and  the  nerve  found  a  little  to  the  inner  side  of  the  biceps. 
The  fatty  tissue  around  it  is  then  carefully  incised  till  the  white 
epineurium  itself  of  the  nerve  is  exposed.  The  nerve,  being  most 
entirely  separated  from  adjacent  parts,  is  now  stretched.  The  force 
Avith  which  this  is  accomplished  must  vary  someAvhatin  different  cases. 
Thus,  in  sciatica,  the  index  fingerf  being  hooked  under  the  nerve, 
this  should  be  raised  well  out  of  its  bed  in  the  hope  of  adhesions 
being  felt  to  give  way  both  at  the  part  stretched  and  at  a  distance  also. 

In  the  case  of  locomotor  ataxy  the  same  amount  of  stretching — 
viz.,  hooking  up  the  nerve  some  2  inches  above  the  level  of  the  skin 
and  some  4  or  5  above  its  bed  this  being  repeated  twice  in  a  centri- 
fugal and  centripetal  direction — has  been  followed  by  satisfactory 
results.  In  other  cases  the  pull  has  been  more  forcible,  care  being 
taken  to  lift  the  limb  off  the  table  several  times.  In  any  case  the 
pull  must  be  without  jerks,  steady  and  continuous,  and  kept  up  for 
some  three  minutes. J  The  direction  of  the  pull,  whether  downwards 
from  the  trunk  or  upwards  from  the  limb,  has  been  a  good  deal  dis- 
puted. Mr.  Marshall  (Bradshaive  Lecture,  p.  28)  thinks  that  in  neu- 
ralgia the  stretching  should  be  performed  both  ways.  In  ataxy  it  is 
essential  to  stretch  down  from  the  body. 

The  nerve,  being  found  to  be  loose  and  elongated,  is  replaced  in  its 
bed,  any  bleeding  points  are  attended  to,  drainage  provided,  and  the 
wound  carefully  closed.  Antiseptic  precautions  must  be  made  use 
of  throughout,  and  the  limb  be  kept  quiet  with  a  splint  or  sand-bags. 
The  tardy  healing  of  the  wound  in  cases  of  ataxy  has  been  already 
alluded  to. 

In  cases  of  stretching  for  sciatica,  gentle  movements  of  the  limb 
should  be  begun  as  soon  as  possible  to  prevent  the  reformation  of 
adhesions. 

*  Ether  should  be  given  in  preference  to  cliloroform,  if  possible.  In  some  cases 
wliere  anaesthetics  seemed  contraindicated,  the  ether  spray  was  made  use  of.  Injec- 
tions of  cocaine  might  be  tried. 

f  In  the  case  of  smaller  nerves  a  blunt  hook  would  be  employed. 

X  Mr.  Marshall  {Ion.  supra  eit.)  thinks  that  a  force  equal  to  30  lb.  or  40  lb.  should  be 
the  limit  for  the  sciatic.  He  thus  gives  an  idea  of  the  above  force  :  "  If  I  first  pull  as 
hard  as  I  imagine  I  should  do  upon  a  living  sciatic  nerve  during  an  operation,  I  find 
that  the  force  employed  is  about  equal  to  20  lb. ;  but  if  I  pull  very  hard,  it  is  in- 
creased to  30  lb.,  and  that,  I  believe,  is  as  hard  as  a  surgeon  could  well  pull  when 
holding  a  soft  nerve  between  his  finger  and  thumb." 


PART  VI. 

OPEEATIOXS  ON  THE  VEETEBRAL  COLUMN. 


SPINA  BIFIDA— TREPHINING  THE  VERTEBRAL 

COLUMN. 

SPINA  BIFIDA. 

Indications. — I  cannot  do  better  than  quote  here  the  conclu- 
sions arrived  at  by  the  Clinical  Society's  Committee  appointed  to 
report  on  this  affection  :  "  1.  Notwithstanding  many  failures,  the  plan 
of  treatment  by  injection  is  the  best  with  which  we  are  acquainted, 
and  the  only  one  which  we  feel  justified  in  recommending.  2.  A 
more  careful  selection  of  cases  than  has  hitherto  been  made  is  neces- 
sary. 3.  Marasmus,  hydrocephalus,  and  intercurrent  disease  contra- 
indicate  the  operation.  4.  In  cases  in  which  the  operation  may 
nevertheless  be  legitimately  performed,  we  should  consider  the  fol- 
lowing as  unfavorable  circumstances :  (a)  Distinct  evidence  of  the 
cord  being  in  the  sac,  as  shown  by  umbilication  or  a  longitudinal 
furrow  ;*  (/5j  A  very  thin  membranous  or  ulcerated  sac  ;  (7)  Previous 
rupture  of  the  sac  ;  (3)  The  occurrence  of  a  distinct  impulse  between 
the  tumor  and  the  anterior  fontanelle,  or  a  sac  the  contents  of  which 
are  easily  returned  into  the  spinal  canal;  (e)  A  very  early  age  of  the 
patient.  5.  The  best  result  is  to  be  hoped  for  in  children  who  have 
reached  the  age  of  two  months,  in  whom  there  is  no  paralysis  or 
hydrocephalus,  and  when  the  sac  is  covered  by  healthy  skin." 

Operations. — 1.  Injection  with  Morton's  Fluid.  2.  Simple 
Tapping  and  Drainage.     3.  Excision. 

All  the  above  are  liable  to  be  followed  by  septic  meningitis  aided 
by  the  constant  soaking  away  of  cerebro-spinal  fluid,  especially  where 
the  coverings  of  the  sac  are  thin  and  unhealthy. 

1.  Injection  with  Morton's  Fluid.— Owing  to  the  large  number 
of  successes  which  have  attended  the  use  of  this  method,  and  the  fact 
that  it  was  recommended  by  the  Committee  of  the  Clinical  Society,  it 
is  the  only  one  which  will  be  given  here  at  any  length.     It  is  impos- 

*  Other  points  which  make  it  probable  that  nerve  trunks  or  the  cord,  or  both,  are 
present  in  the  sac  are  paralysis  of  the  sphincters  or  lower  extremities,  a  large  sessile 
tumor  with  a  broad  base,  and  the  appearance  of  cord-like  bands  when  the  sac  is  thia 
enough  to  transmit  light. 


986  OPERATIONS   ON   THE   VERTEBRAL   COLUMN. 

sible  to  point  out  too  strongly  to  my  j'oung  readers  that  it  is  only  by 
a  judicious  selection  of  cases  that  any  success  can  be  expected.* 

The  sac  being  cleansed,  a  syringe  which  will  hold  about  2  drachms 
of  the  iodo-glycerine  solution  is  chosen,  and  a  fine  trocar.  The  calibre 
of  this  must  not  be  too  fine  for  the  thick  fluidf  which  has  to  pass 
through  it.  The  puncture  in  the  swelling  should  be  made  well  at  one 
side,  obliquely  through  healthy  skin,  and  not  through  the  membranous 
sac-wall,  the  objects  being  to  avoid  wounding  the  cord  or  nerves,  and 
also  to  diminish  the  risk  of  leakage  of  the  cerebro-spinal  fluid.  Un- 
less the  sac  is  very  large  it  is  probably  better  not  to  draw  off  much, 
if  any,  of  the  fluid  from  the  sac  on  the  first  occasion.  The  position 
of  the  child  during  the  injection  has  been  a  good  deal  dwelt  upon, 
most  recommending  that  it  should  be  upon  its  back.  The  Clinical 
Society's  Committee  advise  that  the  child  should  be  laid  upon  its  side. 
About  a  drachm  is  the  quantity  which  they  recommend.  Every  care 
must  be  taken  to  prevent  any  escape  of  the  cerebro-spinal  fluid,  now 
and  later,  it  being  clearly  understood  that  any  leakage,  Avhich  is  most 
difficult  to  prevent,  will  lead  to  septic  meningitis  and  death.  When 
the  needle  is  withdrawn  the  puncture  should  be  pressed  around  it, 
and  immediately  painted  with  collodion  and  iodoform,  a  dressing  of 
dry  gauze  being  also  secured  with  collodion  (p.  803).  I  prefer  to  give 
a  little  chloroform  to  prevent  any  crying  and  straining  at  the  time. 
The  child  should  be  kept  as  quiet  as  possible  afterwards,  on  its  side, 
and  an  assistant  should  make  sure,  for  the  first  hour  at  least,  that  no 
leakage  is  going  on.  Shrinking  of  the  cyst,  setting  in  rapidly  and 
continuing  steadily,  shows  that  all  is  well.  If  the  injection  fail  alto- 
gether, or  oi.ly  cause  partial  obliteration  of  the  sac,  it  should  be 
repeated  at  intervals  of  a  week  or  ten  days. 

2.  Simple  Tapping  and  Drainage.  — This  consists  of  either 
tapping  Avith  a  very  fine  trocar  and  carefully  sealing  the  opening,  or 
inserting  a  single  j)iece  of  horsehair  as  a  drain.  I  have  had  one  suc- 
cessful case  treated  by  the  former  method,  and  four  unsuccessful  ones. 
The  use  of  the  horsehair  drain  is  not  to  be  recommended,  as  the  leakage 
cannot  be  kept  sweet. 

3.  Excision  of  the  Sact — There  is  no  doubt  that  this  method  has 
met  with  a  considerable  amount  of  success,  but  with  regard  to  this  the 

*  The  Clinical  Society's  Committee  collected  71  cases  treated  by  this  method.  Of 
these,  35  recovered,  27  died,  4  were  relieved,  and  5  unrelieved.  In  a  letter  to  the  Com- 
mittee (dated  May  11, 1885)  Dr.  Morton  was  able  to  refer  to  50  cases  thus  treated.  Of 
these,  41  appear  to  have  been  successful,  and  9  unsuccessful. 

t  The  fluid  is  iodine,  gr.  x. ;  iodide  of  potassium,  5J  ;  glycerine,  5J. 

X  The  Clinical  Society's  Committee  collected  23  cases  treated  by  excision  of  the  sac. 
Of  these,  16  recovered,  7  died.  Tliey  point  out  that  no  mention  of  the  contents  of  the 
sac  is  made  in  6  cases;  that  nerves  were  certainly  absent  in  16  cases;  and  that  in  1, 
which  was  fatal,  tliey  were  certainly  present  {Trans.,  vol.xviii.  p.  380). 


TREPHINING   THE   VERTEBRAL   COLUMN.  987 

following  points  must  be  reckoned  with  :  (1)  It  is  probable  that  many 
cases  of  failure  have  not  been  reported.  (2)  In  many  of  the  cases  it 
is  not  stated  with  sufficient  clearness  whether  nerves  were  present  or 
not.  (3)  The  patient  is  exposed  to  the  grave  dangers  of  removal  of  the 
nerves  or  cord. 

The  cases  best  suited  to  this  method  are  those,  of  course,  where 
there  is  something  of  a  pedicle,  or  where  the  gap  in  the  bones  is  very 
small  or  closed.* 

Mr.  Robson  has  recordedf  four  cases  in  which  he  excised  the  sac 
with  the  aid  of  the  eucalyptus  spray,  suturing  the  meningeal  and 
cutaneous  flaps  respectively.  Three  cases  did  well.  Nerves  do  not 
appear  to  have  been  present  in  the  sac.  Mr.  Robson  suggests  that  if 
this  complication  is  present,  portions  of  the  cyst-wall  might  be  removed 
from  between  the  nerves,  and  the  remains  of  the  sac  placed  in  the 
opening  in  the  bones  and  covered  over  with  skin.| 

Causes  of  Failure  after  the  Radical  Cure  of  Spina  Bifida. 

1.  Leakage  and  septic  meningitis. 

2.  Convulsions  and  rapid  death. § 

3.  Paraplegia.  The  setting  in  of  this  after  injection  may  be  tem- 
porary or  permanent. 

4.  Hydrocephalus.  This  also  may  make  its  appearance  after  the 
injection  with  iodo-glycerine. 

5.  No  result,  the  swelling  progressing  unaltered. 

TREPHINING  THE  VERTEBRAL  COLUMN. 

After  Prof.  Horsley's  brilliantly  successful  operation  for  the  removal 
of  a  growth  from  the  spinal  cord,  brought  before  the  Medico-Chirurgical 

Society  this  year,||  this  most  rare  operation  must  be,  though  thus  most 
briefly,  alluded  to. 

*  Dr.  Sinclair  (Dub.  Journ.  Med.  Sci.,  188f>,  vol.  i.  p.  199)  records  a  case  of  successful 
excision.  Here  all  communication  with  the  spinal  canal  was  shut  off  by  a  strong 
vascular  cord.  No  alteration  in  tension  had  occurred  when  the  child  cried,  and  con- 
tinuous pressure  on  the  swelling  had  produced  no  head  symptoms, 

t  Brit.  Med.  Jnurn.,  April  4,  1885. 

X  Any  one  attempting  this  method  would  be  wise  to  remove  portions  of  the  sac  from 
its  sides  only,  suturing  tlie  edges  of  the  wound. 

§  Mr.  Glutton,  who  brought  a  successful  case  of  Dr.  Morton's  treatment  before  the 
Clinical  Society  (Trans.,  vol.  xvi.  p.  34),  mentioned  another  in  whicli  this  treatment 
was  immediately  followed  by  fatal  convulsions.  The  same  proved  fatal  in  about  ten 
hours  in  a  case  under  my  care.  Mr.  Bennett,  during  the  above  discussion,  mentioned 
a  case  in  which,  owing  to  the  child  being  indisposed  at  the  time,  he  declined  to 
operate.  The  child  died  on  its  way  home  of  convulsions.  He  remarked  that  if  he  had 
used  the  injection,  this  would  have  been  credited  with  the  convulsions. 

II  Brit.  Med.  Journ.,  1888,  vol.  i.  p.  191,  1273.  An  account  of  tlie  operation  when 
employed  for  fracture-dislocation  of  the  spine  will  be  found  in  my  article,  "Injuries  of 
the  Back,"  System  of  Surgery,  vol.  i.  p.  682. 


APPENDIX. 


TAPPING  OR  INCISING  THE  PERICARDIUM. 

Indications. 

(1)  When  a  pericardial  effusion  has  resisted  previous  treatment. 

(2)  When  tliere  is  a  steady  increase  of  precordial  dulness. 

(3)  When  the  heart-beat  and  pulse  are  becoming  feeble. 

(4)  When  there  are  cyanosis,  dyspnoea,  and  epigastric  distress. 

(5)  When  the  effusion  persists,  when  it  is  accompanied  by  oedema, 
rigors,  and  pyaemia,  when  it  occurs  in  a  much  weakened  patient,  as 
part  of  pysemia,  the  fluid  is  probably  purulent.* 

The  most  suitable  place  for  puncture  is,  in  ordinary  cases,  the  fifthf 
left  intercostal  space,  about  1  inch  from  the  edge  of  the  sternum,  so  as 
to  avoid  the  internal  mammary  artery, |  the  instrument  being  a  trocar 
and  cannula,  with  or  without  aspiration,  according  to  the  facility  with 
which  the  fluid  flows. §  A  pint  of  serum,  and  in  many  cases  over  a 
pint,  has  been  removed.  The  withdrawal  of  a  much  smaller  amount 
— viz.,  3  or  5  oz. — has  been  followed  by  recovery.] | 

A  preliminary  puncture  being  made  with  a  scalpel,  the  trocar — in 
the  case  of  serum,  a  h3^drocele  trocar  will  probably  be  sufficient — 

*  In  Dr.  West's  case  {Med.  Chir.  Trans.,  vol.  Ixvi.  p.  266),  treated  successfully,  first  by 
tapping  and  then  by  free  incision,  there  were  no  rigors  or  sweating,  but  oedema  of  the 
chest-walls,  most  marked  over  the  precordial  region,  was  present.  So,  too,  in  a  patient 
of  Prof.  Rosenstein's,  a  boy  aged  ten,  with  a  large  purulent  pericardial  effusion,  the 
temperature  was  hardly  above  normal,  and  there  was  no  oedema. 

t  The  fourth  space  has  also  been  chosen  in  many  cases. 

X  And  also  to  avoid  opening  the  pleura.  When  this  is  adherent  to  the  pericardium, 
the  tapping  or  incision  can,  of  course,  be  made  farther  out.  But  Dr.  West,  who  chose 
the  nipple  line  for  his  puncture  and  opening  as  the  spot  where  the  heart  was  farthest 
from  the  chest-walls,  found  that  a  long  sinus  formed — an  argument  for  puncturing 
nearer  the  sternum. 

§  In  Dr.  West's  case  the  pus  was  very  viscid,  and  flowed  slowly ;  the  cannula  was 
accordingly  connected  with  the  aspirator,  and  about  14  oz.  obtained. 

II  With  regard  to  the  amount  to  be  withdrawn,  Dr.  Stewart  (Edin.  Med.  Journ., 
August,  1885y  thinks  that,  if  serous  fluid  is  found,  aspiration  should  be  made  use  of,  but 
only  enough  withdrawn  to  give  relief.  He  points  out  that  it  is  a  sound  rule,  in  dealing 
with  vital  organs,  that  only  a  minimum  amount  of  interference  should  be  had  recourse 
to,  and  that  this  is  especially  necessary  in  cases  which  threaten  pulse-failure.  The  tap- 
ping should  be  repeated  rather  than  too  much  fluid  be  drawn  off  at  once. 


APPENDIX.  989 

Bcrupuloush'  clean,  should  be  steadily  pushed,  with  aseptic  precau- 
tions, for  I4  or  2  inches  through  the  chest- wall,  and  at  a  right  angle* 
to  it.  The  trocar  should  then  be  removed,  and,  if  fluid  does  not  flow, 
the  point  will  probably  be  found  not  to  move  freely  in  a  cavity.  It 
should  then  be  pushed  cautiously  onwards,  and  its  point  at  once 
sheathed  if  it  is  felt  "^^o  touch  against  a  soft  obstacle. 

On  the  fluid  ceasing  to  flow,  the  puncture  should  be  closed  with  collo- 
dion and  iodoform. 

Dr.  West  thinks  {loc.  mpra  cit.)  that  paracentesis  pericardii  may  be 
performed  with  advantage,  not  only  in  the  pericardial  effusions  of 
rheumatic  or  primary  origin,  but  also  in  those  which  occur  in  the 
later  stages  of  general  dropsy,  if  it  should  appear  that  the  fluid  in  the 
pericardium  is  adding  to  the  difficulties  under  which  the  heart  is 
placed.  According  to  the  cases  which  he  has  collected,  with  one  ex- 
ceptionf  all  the  patients  were  much  relieved  by  the  removal  of  even 
a  small  amount  of  fluid,  and  many  recovered  completely  who  would 
probably  have  died  if  the  operation  had  not  been  performed. 

The  coexistence  of  eflFusion  into  the  pleurse  and  peritoneal  cavity  in 
many  of  these  cases  must  be  remembered. 

If  pus  is  present  the  case  must  be  treated  by  free  incision.  An 
anaesthetic  being  given,!  the  trocar  is  taken  as  a  guiding  director,  and 
a  narrow  sharp-pointed  bistoury  carefully  thrust  in  by  its  side,  and 
the  opening  further  dilated  with  dressing-forceps  or  a  blunt-pointed 
bistoury,  care  being  taken  to  keep  the  internal  opening  into  the  peri- 
cardial sac  free.  A  large  soft  drainage-tube  should  then  be  inserted, 
and,  when  all  the  pus§  that  will  come  away  has  escaped,  asej^tic  gauze 
dressings  should  be  applied. 

Dr.  Gussenbauer,  in  a  patient  aged  fifteen,  with  purulent  pericarditis 
after  osteo-myelitis,  resected  part  of  the  fifth  rib  before  incising  the 
pericardium,  and  the  patient  recovered.     While  this  is  an  improve- 

*  Mr.  Godlee  (Diet,  of  Surg.,  vol.  ii.  p.  164)  says  close  to  the  sternum,  and  obliquely 
upwards  and  outwards,  so  as  to  avoid  wounding  the  heart. 

f.  In  this  case,  No.  51  in  Dr.  West's  list,  death  took  place,  five  minutes  after  the 
puncture,  from  haemorrhage  into  the  pericardium  from  injury  to  the  right  ventricle. 
But  in  another  case,  No.  29,  the  patient  died  two  hours  after  the  operation,  the  left 
pleura  being  found  to  contain  air  and  blood,  the  latter  coming  from  a  puncture  in  the 
heart. 

X  Chloroform  will  perhaps  be  the  wisest,  especially  if  pleural  effusion  co-exists,  on 
account  of  the  greater  struggling  with  ether.  It  was  well  taken  jn  Dr.  West's  case. 
Punctures  for  cocaine  injection  will  be  painful,  and  very  likely  futile. 

^  In  Dr.  West's  case,  a  boy  aged  sixteen,  this  was  estimated  at  two  quarts.  If  the  pus 
is  foul,  but  not  otherwise,  the  cavity  should  be  syringed  out  with  dilute  carbolic  acid, 
or  mercury  perchloride  solution. 


990  APPENDIX. 

ment  on  the  now  abandoned  method  of  trephining  the  "sternum,  it 
cannot  often  be  required. 
Causes  of  Failure. 

1.  The  heart  fatty  or  dilated.     These  changes  may  come  on  very 
rapidly. 

2.  The  pericardium  much  thickened  and  adherent. 

3.  Coexisting  effusions  into  the  pleurae  and  peritoneal  cavity, 

4.  GEdema  of  the  lungs.     Evidence  of  this  should  be  most  carefully 
watched  for. 

5.  Coexisting  diseases — e.g.,  phthisis  and  renal  disease. 


INDEX  OF  NAMES 


Aberxethy,  liorature  of  external  iliac,  535 
Adams,  division  of  contracted  palmar  fascia,  32 
Allingham  (H.),  inguinal  colotomy,  607 
Allingham  !  W.),  excision  of  rectum,  828 
Amussat's  operation,  763 

AxGER,  "distance  sutures"  in  uniting  tendons,  39 
Aveling's  method  of  transfusion,  84 

Baker  (M.),  lumbar  colotomy  in  imperforate  rectum,  606;  removal  of  the  tongue,  337 

Ball,  toi'sion  of  sac  in  radical  cure  of  hernia,  587 
•  Banks  (M.),  excision  of  shoulder  for  enchondroma,  128;  removal  of  nasal  polypi,  265; 
imperative  need  of  extensive  operations  in  breast  cancer,  .508 ;  radical  cure  of  hernia, 
578,  580,  5S2;  ligature  of  the  first  part  of  the  subclavian,  475 

Barker,  operation  for  ununited  clavicle,  149 ;  removal  of  a  deep  growth  in  the  neck, 
410;  wound  of  obturator  artery  in  operations  for  femoral  hernia,  567  ;  case  of  gasti'o- 
enterostoiny,  697  :  excision  of  hip  by  anterior  incision,  864  ;  excision  of  knee  by  a 
semilunar  flap,  901 ;  method  of  excision  of  astragalus,  953 

Barwell,  ligature  of  the  first  part  of  the  subclavian,  476;  diagnosis  of  aortic  and  in- 
nominate aneurism,  488,  490 

Bal'M,  operation  for  stretching  facial  nerve,  237 

Bexnet  (W.  H.),  removal  of  wedge  of  bone  for  talipes,  957;  sudden  death  in  spina 
bifida,  987 

Berxays,  curetting  of  cancer  of  stomach,  699 

Billroth,  date  of  hare-lip  operations,  304 ;  repetition  of  operation  in  hare-lip,  314  ;  pre- 
liminary ligatui-e  of  Unguals  in  removal  of  tongue,  333 ;  excision  of  pylorus,  694 

Briggs,  opei'ative  treatment  of  traumatic  epilepsy,  187, 183 

Brixtox,  amputation  through  knee-joint,  893 

Browxe  (L.),  case  of  removal  of  half  the  larynx,  330 

Bruxs,  excision  of  knee,  899 

Bryaxt  (T.),  amputation  through  knee-joint,  892;  case  of  colectomy,  664;  puncture 
per  rectum,  780 

Bryaxt  (New  York),  ligature  of  external  carotid,  447,  450 

BUCHANAX,  restoration  of  lower  lip,  316 

BUTLix,  the  value  of  microscopic  examination  of  tongue  ulcer,  325;  removal  of  tongue 
by  Kocher's  method,  339 ;  mortality  after  laryngectomy,  372  ;  malignant  disease  of 
kidney,  626  ;  malignant  disease  of  pylorus,  691 

Cadge,  lithotomy  in  little  children,  745 ;  recto-vesical  fistula  after  lateral  lithotomy,  746 ; 
the  size  of  stone  in  lithotomy,  749  ;  recurrence  of  stone  after  lithotomy  and  lithot- 
rity,  761 ;  lithotrity  and  litholopaxy,  758,  761 

Callisex's  operation,  590 

Cardex's  amputation,  885 

Carxochan's  operation  on  second  division  of  fiftli  nerve,  232 

Chavasse,  neurectomy  of  fifth  nerve,  232 

Cheever's  method  of  removing  tonsillar  growths,  342 

Chopart's  amputation,  957;  method  of  restoring  lower  lip,  316 

Cixiselli,  galvanic  puncture  in  thoracic  aneurism,  498 

Clemot,  operation  for  hare-lip,  303 

Cluttox,  neurectomy  of  fifth  nerve,  232  ;  treatment  of  thyroid  cysts,  404 

Cock,  perineal  section,  external  ui-ethrotomy  without  a  guide,  787 

Cooper  (Sir  A.),  trephining,  166;  ligature  of  external  iliac,  533;  ligature  of  abdominal 
aorta,  556,  557 

Cripps,  method  of  transfusion,  84;  ligature  of  external  carotid,  446;  treatment  of 
wound  of  thigh,  876;  hsemorrhage  from  posterior  tibial  artery,  912;  removal  of 
rectum,  828 

CURLIXG,  operation  for  varicocele,  813 

CzERXY,  method  of  removing  tonsillar  growths,  343;  ligature  of  abdominal  aorta  dur- 
ing nephrectomy,  637 


992  I^'DEX   OF   NAMES. 

Davies-Colley,  partial  resection  of  head  of  humerus,  134;  colotomy  by  two  st;rj;es,  use 

of  pins  in,  (JOO ;  removal  of  wedge  of  tarsal  bones  for  inveterate  talipes,  95ti 
Davy,  rectal  lever,  846 ;  removal  of  wedge  of  bone  for  inveterate  talipes,  956 
Delegarde,  suture  of  extensor  tendons  in  Chopart's  amputation,  958 
DiDOT,  webbed  fingers,  31 

DiEFFENBACH,  restoration  of  angle  of  mouth,  316 
Dietrich,  ligature  of  vertebral,  464 
DUBREUIL,  amputation  at  wrist,  51 
Duncan  (J.),  re-infusion,  89 
DUPLAY,  iiypospadias,  799 
DUPUY'TREN,  cerebral  abscess,  162 
Durham,  electrolysis  of  hydatids,  706 

Edinburgh  Surgeons  on  re-infusion,  89 

Erichsen,  treatment  of  inflamed  axillary  aneurism,  115;   excision  of  shoulder,  126; 

ligature  of  common  femoral,  869;  operation  for  varicocele,  812 
Esmarch,  fixity  of  lower  jaw,  302 

Fenger,  exploration  of  cerebral  abscess,  183;  resection  of  ribs,  521 

Fergusson  (»Sir  W.),  date  of  operation  for  hare-lip,  303 ;  treatment  of  pre-maxillary  bone, 

311,  313;  operation  for  hard  pahite,  322;  lithotomy  in  little  children,  745 
Forster  (J.  Cooper),  avulsion  of  naso-pharyngeal  polypus,  279 

Fowler  (G.  E.  ),  operations  on  the  fifth  nerve,  231,  232 ;  ununited  fracture  of  patella,  912 
FuRNEAUX  Jordan,  amputation  at  shoulder-joint,  125;  at  hip-joint.  844 

Galabin,  transfusion,  83  ;  ruptured  perineum,  838 

Gebster,  case  of  unilateral  laryngectomy,  381 

GiRALDES,  position  of  sigmoid  in  imperforate  rectum,  606 

GoDLEE,  trephining  for  cerebral  tumor,  216;  stretching  of  facial  nerve,  236;  resection 
of  ribs,  521 ;  drainage  of  lung  cavities,  527;  abdominal  section  for  obturator  hernia, 
598;  case  of  suppurative  peritonitis  treated  by  abdominal  section,  661 

GoLDiNG  Bird,  removal  of  tonsillar  growths,  342;  jejunostomy,  699;  trans-patellar  ex- 
cision of  knee,  901 

GooDHART,  Margate  air  for  empyema,  518;  inflation  in  intussusception,  647 

Gould,  amputation  of  penis,  806 

Gregory,  amputation  in  case  of  hand  flayed  by  machinery,  29 

Greig  Smith,  nephrectomy,  631,  632  ;  abdominal  section  for  intestinal  obstruction,  657; 
removal  of  biliary  calculi,  708;  removal  of  uterine  appendages,  721,  722;  removal 
of  cancerous  uteru^.,  730,  732;  ectopia  vesicje,  796 

GuNN,  deferred  operations  for  old  depressed  fracture  of  the  skull,  157 

GussENBAUER,  resectiou  of  rib  for  incision  of  pericardium,  989 

Guthrie,  cut-throat  wound  of  common  cai-otid,  428  ;  amputation  at  hip-joint,  852 

Hardie,  contracted  palmar  fascia,  35 

Hare,  venesection,  80 

Harrison  (R.),  urethrotome,  791;  puncture  of  bladder  through  prostate,  781 

Heath,  amputation  at  shoulder-joint  for  gangrene,  114;  removal  of  scapula  together 
witli  upper  extremity,  144  ;  removal  of  jaws,  271,  291,  295;  fixity  of  lower  jaw,  303  ; 
control  of  hiemorrhage  from  a  divided  lingual,  333 

Hewson,  comparison  of  Syme's  and  Pirogoft"s  amputations,  944 

Hey's  amputation,  960 

Hill  (B.),  internal  urethrotomy,  791,  792,  793 

Hilton,  fissure  of  anus,  826 

Hoffa,  mortality  after  hare-lip  operations,  313  ;  shortening  met  with  after  excision  of 
knee,  904 

HoLDEN,  on  trephining,  166 

Holl,  frequency  of  rudimentary  condition  of  twelfth  rib,  614 

Holmes,  treatment  of  axillary  aneurism,  112;  value  of  sub-periosteal  excision  of 
shoulder-joint,  135;  pus  between  bone  and  dura  mater,  169;  treatment  of  pre-max- 
illary bone  in  hare-lip,  310;  diagnosis  of  wounds  of  the  vertebral,  461  ;  ligature  of 
subclavian,  466;  ligature  of  innominate,  478;  surgical  interference  in  thoracic 
aneurism,  490,  493,  498 ;  ilio-femoral  aneurism,  528 ;  ligature  of  the  common  iliac, 
540  ;  glutseal  aneurism,  552  ;  Prof.  Loreta's  cases  of  dilatation  of  the  stomach  ori- 
fices, 687;  ligature  of  common  femoral,  869;  condition  of  the  limb  after  excision  of 
the  knee,  895;  excision  of  ankle,  947;  of  os  calcis,  953 

Holt,  aneurism  of  brachial,  93 

HoRSLEY,  removal  of  brain  scar  for  traumatic  epilepsy,  188 ;  tubercular  tumor  of  brain, 
221  ;  method  of  operating  on  the  brain,  227  ;  eifects  of  thyroidectomy,  390  ;  trephin- 
ing vertebral  canal,  987 

HowsE,  detection  of  stone  in  nephro-lithotomy,  615  ;  gastrostomy,  680 ;  circumcision,  801 ; 
varicocele,  811 ;  splint  for  excision  of  knee,  906  ;  sequestrotomy,  933 


INDEX   OF   NAMES.  993 


HuETER,  stretching  facial  nerve,  237 

HuGUiER,  position  of  sigmoid  in  cases  of  imperforate  rectum,  G06 

HULKE,  fracture  of  inner  wall  of  orbit,  160 ;  trephining  cerebral  abscess,  184 ;  cerebel- 
lar abscess,  196 

HuTCHixsox,  excision  of  shoulder  for  myeloid  growth,  130;  mode  of  preventing  haem- 
orrhage in  scalp  operations,  151 ;  state  of  pupil  in  middle  meningeal  haemorrhage, 
177;  operative  treatment  of  lupus,  240  ;  intussusception,  649;  acute  intestinal  ob- 
struction, question  of  operative  interference  in,  652 

Irish  Surgeons,  ligature  of  common  femoral,  869 

Keegan,  litholapaxT  in  male  children,  769 

Keen,  stretching  fac^'al  nerve,  238 

KiRMissox,  removal  of  growths  from  Scarpa's  triangle,  867 

KocHER,  excision  of  tongue,  327;   myxcedema  after  thyroidectomy,  390,  391 

KoNiG,  value  of  free  incision  in  lumbar  nephrectomy.  631 

KoRTE,  rupture  of  axillarj-  artery  in  shoulder  dislocation,  112 

Lange,  importance  in  kidney  operation  of  a  rudimentary  state  of  the  twelfth  rib,  614 
Lakgenbeck,  excision  of  wrist,  46  ;  removal  of  naso-pharyngeal  polypus  through   the 

nose,  286  ;  incision  for  nephrectomy,  289 
Larrey,  amputation  at  hip-joint,  852 

Lawrence  (Sir  WJ,  removal  of  naso-pharyngeal  polypus  tlirough  the  nose,  285 
Lee  (Chicago),  trephining  for  cerebral  abscess,  183 
Lee  fH.),  operation  for  varicocele,  813 
Lembert's  suture  of  intestine,  666 

Lisfranc.  amputation  at  hip-joint,  852 ;  amputation  through  tarso-metatarsal  joints,  960 
Lister  (Sir  J.),  excision  of  wrist,  42;  wiring    ununited   fracture  of  olecranon,  78;  on 

Garden's  amputation,  885  ;  treatment  of  compound  fractures,  935 
Longmore  'Sir  T.),  excision  of  radius  and  ulna  in  military  surgery,  59;  excision  of  the 

shoulder,  131 ;  gunshot  injuries  of  the  knee,  897 
LoRETA,  dilatation  of  stomacli  orifices,  687 
Lossen,  iieurotomy  of  the  fifth  nerve,  234 
Lucas  (E.  C),  excision  of  lower  end  of  ulna  for  myeloid  sarcoma,  58  ;  radical  cure  of 

umbilical  hernia,  576;  bspmorrhage  after  nephrectomy,  634;   successful  uephro-lith- 

otomy  four  months  after  nephrectomy,  642 
Lucas-Championniere,  cerebral  localization,  215 
Lucke,  neurectomy  of  the  fifth  nerve,  234 

MacCormac  (Sir  W.),  rhinoplasty  by  the  Italian  method,  261;  removal  of  the  thyroid 
gland,  393,  395,  396  ;  treatment  of  ruptured  bladder,  776 ;  ligature  of  popliteal  artery 
from  the  front,  920;  case  of  Mickulicz's  operation  on  the  tarsus,  954 

Macewen,  restoration  of  humerus  by  bone  grafts,  102;  replacement  of  bone  after  tre- 
phining, 168;  trephining  for  cerebral  abscess,  182;  supra-condyloid  osteotomy  of 
femur,  966 ;  osteotomy  of  tibia  as  well  as  femur,  969 

MACLEOD,  on  Syme's  amputation,  939 

Maisonneuve's  and  Guerin's  operation  for  naso-pharyngeal  polypus  by  partial  re- 
moval of  the  upper  jaw,  287 

Makins,  closure  of  artificial  anus,  662 

Marsh  (H.),  nephrectomy  for  pyelitic  kidney,  630;  intussusception,  650;  haemorrhage 
after  cleft-palate  operations,  324  ;  excision  of  hip,  854  ;  removal  of  loose  bodies  from 
knee-joint,  916 

Mears,  neurectomy  of  fifth  nerve,  235 

MiCKTJLicz,  removal  of  tonsil  growths,  344;  myxcedema  after  thyroidectomy,  393 ;  opera- 
tion on  tarsus,  954 

MiRAVLT,  operation  for  hare-lip,  309 

Moore,  removal  of  rodent  ulcer,  243,  245,  246;  causes  of  failure  after  removal  of  breast, 
504  ;  introduction  of  wire  into  aneurismal  sac,  496 

Morris,  removal  of  myeloid  growth  of  radius,  ,57;  restoration  of  Steno's  duct,  240; 
nephro-lithotomy,  615  ;  nephrectomy,  624,  642  ;  nephrorraphy,  644  ;  radical  cure  of 
hydrocele,  810 

MoTT,  removal  of  clavicle,  146;  ligature  of  innominate,  480 

Nancrede,  trephining,  156,  157;  cerebral  abscess,  162;  cerebral  localization,  213;  oper- 
ative interference  in  abdominal  injuries,  669 
Nelaton,  naso-pharyngeal  polypus,  282;  hare-lip,  309;  right  iliac  enterotomy,  659 
Norton,  webbed  fingers,  31 

Ogston,  trephining  frontal  sinuses,  208 ;  osteotomy  for  genu  valgum,  969 

63 


994  INDEX   OF   NAMES. 

Ollier,  sub-periostea]  excision  of  shoulder,  135  ;  removal  of  naso-pharyngeal  polypus 
through  nose,  286 ;  preservation  of  lateral  ligaments  in  knee  excision,  903  ;  infre- 
quent dressings  after  knee  excision,  901 

Otis,  on  gunshot  injuries,  excision  of  wrist,  47;  radius  and  ulna,  59;  elbow,  75;  inju- 
ries at  bend  of  elbow,  96;  humerus,  101;  shoulder,  137;  ligature  of  external  iliac 
for  secondary  hsemorrhage  from  femoral,  531;  hii^-joint,  859;  knee,  897 

Paget  (Sir  J.i,  site  of  stricture  in  femoral  hernia,  560;  condition  of  intestine  in  stran- 
gulated hernia,  565 

Paget  (S.),  growths  of  palate,  324 

Pancoast,  neurectomy  of  fifth  nerve,  234 

Parker  (Robert),  thyrotoniy,  346  ;  angular  tracheotomy  tubes,  352;  size  of  tubes,  352  ; 
suturing  bladder  in  supra-pubic  lithotomy,  754;  excision  of  hip  by  anterior  incision, 
863 

Parker  (Rushton),  malformation  of  anus  and  rectum,  835 

Parkes,  operative  interference  in  abdominal  injuries,  668 

Pick,  amputation  through  knee-joint,  893 

Pilcher,  suturing  bladder  in  supra-pubic  lithotomy,  754;  removal  of  growths  from 
Scarpa's  triangle,  868 

Pirogoff's  amputation,  943;  contrasted  with  Syme's,  943 

Pitts,  stretching  inferior  dental  nerve,  235;  tumor  of  bladder,  738 

Poland  (A.),  ligature  of  subclavian,  467 

Pollock,  i)artial  removal  of  scapula,  139 ;  occasional  inveteracy  of  hydrocele,  810 ; 
crushing  piles,  824;  amputation  through  knee-joint,  893 

Porter,  amputation  at  shoulder-joint,  121 ;  excision  of  ankle,  950 

Pye,  excision  of  wrist  for  injury,  47 

Roberts,  spiculation  of  internal  table,  158 

Rouge's  operation,  264,  285 

RoussELL,  transfusion,  86 

Roux's  amputation,  941 

RoYES  Bell,  excision  of  thumb  phalanx  for  enchondroma,  27 

Savory,  haemorrhage  from  malignant  disease  opening  axillary  artery,  106 

ScHAFER,  arterial  transfusion,  90 

Sedillot,  restoration  of  upper  lip,  316 

Serre.  restoration  of  lower  lip,  314 

Sheild,  excision  of  shoulder  for  unreduced  dislocation,  128 

Skey,  recurrent  hii-nidrrliage  from  wound  of  palm,  37  ;  method  of  rhinoplasty, 263;  am- 
putation of  metatarsus,  960 

Smith  (H.),  clamp  and  cautery  in  piles,  823 

Smith  (S.),  amputation  through  knee-joint,  891 

Smith  (T.),  clct't-palate,  319  ;  bare-lip," 304  ;  supra-pubic  puncture  of  the  bladder,  779 

Spanton,  radical  cure  of  hernia,  588 

Spence,  amputation  of  shoulder-joint,  120 

Stimson,  treatment  of  ruptured  axillary  artery,  112 

Syme,  old  operation  for  ligature  of  axillary  artery.  111 ;  common  carotid,  442;  glutseal, 
554  ;  rhinoplasty,  256;  restoration  of  lower  lip,  315;  removal  of  tongue,  327  ;  extei"- 
nal  urethrotomy,  783  :  amputation  at  ankle,  936 

Symonds  (C.  J.),  removal  of  scapula,  143;  dilatation  of  malignant  disease  of  oesophagus, 
679  ;  (with  Dr.  Mahomed)  removal  of  concretion  from  vermiform  appendix,  661 ;  ex- 
panded kidney  in  nephro-lithotomy,  617 

Tait  (L.),  biliary  calculi,  709 

Taylor  (F.),  inflation  in  intussusception,  647 

Thompson  (Sir  H.),  bladder  growths  classification,  736;  removal,  737;  litholapaxy,  758, 

764  ;  supra-pubic  lithotomy,  750,  751 ;  urethrotome,  795 
Thornton  (K.),  treatment  of  ureter  in  nephrectomy,  637;  enucleation  of  ovarian  cysts, 

718  ;  removal  of  cancerous  uterus,  729,  732 ;  gastrotomy,  685 
Tiffany,  suture  of  tendon  to  flaps  in  finger  amputation,  20 
TiLLAUX,  musculo-spiral  nerve  embedded  in  callus,  105 

Vogt,  fat  embolism  after  knee  excision,  909 
Volkmann,  treatment  of  lupus,  240 

Walsham,  treatment  of  epilensy,  185  ;   stone  in  female  children,  773 
Ward  (O.  .  united  fracture  of  patella,  911,  915 
Watson  (E.),  modification  of  Pirogofi"s  amputation,  945 
Watson  (P.  H.),  extensive  removal  of  tarsus,  955 
West,  excision  of  the  wrist,  45 


INDEX   OF    NAMES.  995 


West  (S.),  tapping  and  incising  the  pericardium,  988 

Wheelhouse,  tourniquet  pressure  on  abdominal  aorta,  528 

White  (Hale),  cerebral  tumors,  222 ;  state  of  cranial  bones  in,  222 

Whitehead,  removal  of  tongue,  327 ;  operation  for  piles,  824 

Wilde's  incision,  194 

Williams,  drainage  of  lung  cavities,  524 

Wood,  radical  cure  of  hernia,  inguinal,  587;  femoral,  590;  umbilical,  590 

Wright  (G.  A.),  excision  of  wrist,  45  ;  conditions  simulating  renal  calculus,  613  ;  exci- 
sion of  hip,  854  ;  excision  of  knee  for  infantile  paralysis,  900;  erasion  of  knee,  910  ; 
excision  of  astragalus,  952 


GENERAL  INDEX. 


Abdomen,  operative  interference  in  gnnshot  injuries  of,  666 

Abdominal  incision  in  nephrectomy,  witliont  opening  peritoneum,  639 

Abdominal  section  for  ligature  of  abdominal  aorta,  555;  ligature  of  internal  iliac,  550; 
for  strangulated  obturator  hernia,  550;  in  nephrectomy,  635;  acute  intestinal  ob- 
struction, 651,  655;  in  gunshot  injuries,  666 

Abnormalities  of  brachial  artery,  95 

Abscess,  cerebellar,  from  ear  disease,  195,  196;  trephining  for,  196 

Abscess,  cerebral,  from  foreign  bodies  in  the  skull,  162;  from  injury,  180;  from  ear 
disease,  195;  trephining  for,  196 

Abscess,  hepatic,  opening,  707 

Abscess  in  brain  from  ear  disease,  195 

Abscess  in  brain  or  cerebellum,  195 

Abscess,  mastoid,  192,  193;  incision  of,  194;  trephining  for,  194 

Abscess  of  liver,  opening,  707 

Acid,  application  of,  in  piles,  824;  prolapsus,  827 

Acute  intestinal  obstruction,  651;  chief  varieties  of,  645;  exploration  in,  651,  655 

Adhesions,  of  bowel  in  hernia,  564;  in  ovarian  tumors,  714,  716 

Age,  influence  of,  in  tracheotomy,  348;  in  empyema,  511;  in  excision  of  the  hip,  858  ; 
in  excision  of  the  knee,  894 

Aids  in  reduction  of  intestine  in  strangulated  hernia,  570;  in  recognizing  the  sac  in 
hernia  operations,  561 

Aids  to  finding  the  bowel  in  colotomy,  597;  renal  calculus,  615 

Air  passages,  foreign  bodies  in,  366 

Amptitation,  of  arm,  96,  different  methods,  97;  skin  flaps,  97;  transfixion  flaps,  97; 
circular,  100;  mixed  method,  100;  Garden's,  885;  Chopart's,  957  ;  at  elbow-joint, 
64;  practical  points,  64,  different  methods  65,  mixed,  65;  circular,  67;  lateral 
flaps,  66  ;  forearm,  practical  anatomical  points,  60 ;  different  methods,  60;  skin 
flaps,  60;  transfixion,  62;  circular,  64;  fingers,  17;  practical  points,  17,  different 
methods,  18;  distal  phalanx,  17  ;  second  phalanx,  19 ;  at  metacarpo-phalangeal 
joint,  22;  Gritti's,  884,  887  ;  at  hip-joint,  844,  852  ;  flap  methods,  859  ;  lateral 
flaps,  852;  antero-posterror  flaps,  853;  Furneanx  Jordan's  method,  848;  different 
means  of  arresting  haemorrhage,  845 ;  Hey's,  960 ;  knee-joint,  891 ;  lateral  flaps, 
891;  antero-external  and  postero-internal  flaps,  893;  leg,  different  methods,  928: 
lateral  skin  flaps,  928  ;  Teale's  method,  930  ;  in  compound  fractures,  936 ;  in  acute 
necrosis,  960;  Lisfranc's,  960 ;  of  penis,  803;  Pirogoff''s,  943;  at  shoulder-joint, 
different  methods,  117  ;  means  of  arresting  haemorrhage,  117  ;  by  lateral  flaps, 
118;  Spence's  method,  120  ;  by  superior  and  inferior  flaps,  122  ;  by  deltoid  flap, 
124;  by  anterior  and  posterior  flaps,  124;  Furneaux  Jordan's  metiiod,  125;  for 
axillary  aneurism,  115;  for  subclavian  aneurism,  114;  Skey's,  960;  Stokes-Gritti's, 
884,  887;  Syrae's,  939;  contrasted  with  PirogoflF's,  943';  Roux's  modification, 
942;  subastragaloid,  946;  of  thumb,  pihalanges,  25;  at  carpo-metacarpal  joint, 
25;  of  toes,  963;  of  great  toe,  964;  through  thigh,  878;  practical  points,  878; 
different  methods,  878;  mixed  an tero- posterior  flaps,  878;  by  transfixion,  880  ; 
circular,  882  ;  by  Teale's  method,  883 ;  by  lateral  flaps,  883 ;  at  wrist-joint,  different 
methods,  49  ;  long  palmar  flap,  50  ;  equal  antero- posterior  flaps,  Dubreuil's  method, 
51 ;  circular  method,  51 ;  Teale's  method,  52 

Aneurism,  of  aorta  and  innominate,  488;  aortic,  tracheotomy  in,  364;  axillary,  110, 
466;  old  operation  for.  111 ;  cases  requiring  amputation  at  shoulder-joint,  114  ; 
brachial,  92;  arterio-venous,  91 ;  of  common  carotid,  431,  old  operation  for,  442  ; 
of  external  carotid,  432,  by  anastomosis  of  branches  of  external  carotid,  449 ;  of 
internal  carotid,  433,  456;  femoral,  869;  glutseal,  551,  old  operation  for,  554: 
ilio-femoral,  iliac,  femoral,  inguinal,  528,  539;  poplitseal,  871,  ruptured  912; 
radial  and  ulnar,  traumatic,  53;  simulated  by  pulsating  tumors,  543;  subclavian 
and  subclavio-axillary,  467  ;  temporal,  419  ;  vertebral,  460 


GENERAL    INDEX.  997 

Aneurism  needles,  470 

Ankle,  excision  of,  947 

Anterior  tibial  artery,  ligature  of,  925,  926,  927 

Antiseptic  excision  of  hydrocele,  810:  of  veins  in  varicocele,  811 

Antiseptic  incision  of  hydrocele,  808 

Antrum,  epithelioma  of,  269;  relation  of  a  growth  to,  272;  tapping,  292 

Anus,  artificial,  formation  of,  658  ;  closure  of,  661 ;  imperforate,  835 

Aorta,  abdominal  ligature  of,  557,  558 

Appendages,  uterine,  removal  of,  721 

Arm,  amputation  of,  96  ;  different  methods,  97;  by  skin  flaps,  97;  by  transfixion,  98; 
combined  method,  100;  circular,  100 

Arterial  transfusion,  90 

Arterio- venous  aneurism  at  bend  of  elbow,  91 

Artery,  abdominal  aorta,  ligature  of,  through  the  peritoneum,  557  ;  behind  the  peri- 
toneum, 558;  anterior  tibial,  ligature  of,  in  compound  fracture,  925  ;  at  junction 
of  upper  and  middle  third  of  leg,  926  ;  at  junction  of  lower  and  middle  third,  927  ; 
axillary,  ligature  of  first  part,  106;  ligature  of  third  part,  110;  old  operation, 
110;  rupture  in  dislocation  ot^  shoulder,  treatment,  112;  brachial,  ligature  of,  at 
bend  of  elbow,  91 ;  in  the  middle  of  the  arm,  92;  carotid,  common,  ligature  of, 
427  ;  high  operation,  429  ;  low,  440;  temporary  ligature,  441 ;  old  operation,  442  ; 
question  of  ligature  of  common  or  external  carotid,  433,  446  ;  carotitl,  external, 
ligature  of,  446  ;  above  and  below  digastric,  453,  455  ;  carotid,  internal,  ligature 
of,  455  ;  rareness  of  wounds  of,  446  ;  dorsalis  pedis,  ligature  of,  938  ;  facial,  ligature 
of,  421 ;  femoral,  common,  ligatin-e  o*",  432;  injury  of  in  removal  of  growths,  867  ; 
question  of  ligature  of  vein,  868;  femoral,  superficial,  ligature  of,  in  Scarpa's  tri- 
angle, 871  ;  wound  of  vein,  875;  ligature  in  Hunter's  canal,  875;  wound  of,  in 
niidthigh,  875  ;  glutaeal,  ligature  of,  551  ;  by  the  old  operation,  654 ;  iliac,  common, 
ligature  of,  538  ;  by  anterior  incision,  545  ;  by  posterior  incision,  546  ;  iliac,  ex- 
ternal, ligature  of,  528:  by  Sir  A.  Cooper's  method,  533;  by  Abernethy's,  535  ; 
iliac,  internal,  ligature  of,  548,  550;  by  laparotomy,  550;  interior  thyroid,  see 
Thyroid  Arteries;  innominate,  ligature  of,  477,  480;  internal  carotid,  see  Carotid  ; 
internal  iliac,  .s<^e  Iliac,  Internal ;  lingual,  ligature  of,  424,  under  the  hyo-glossus, 
425  ;  of  first  part,  427  ;  middle  meningeal,  hemorrhage  from,  after  trephining, 
177  ;  occipital,  ligature  of,  421,  423;  palmar  arches,  haemorrhage  from,  36  ;  pero- 
neal, ligature  of,  928;  poplitteai,  ligature  of,  from  behind,  920 ;  from  in  front, 
920  ;  posterior  tibial,  ligature  of,  920  ;  in  middle  of  leg,  924;  in  lower  third,  924  ; 
at  inner  ankle,  925;  radial,  ligature  of,  on  back  of  wrist,  52;  in  forearm,  53;  in 
lower  third,  54;  in  middle  third,  54;  in  upper  third,  55  ;  subclavian,  ligature  of, 
in  its  second  and  third  parts,  465,  467  ;  ligature  of,  first  part,  475  ;  in  thoracic 
aneurism,  493;  temporal,  ligature  of,  419;  arteriotomy  of,  420;  thyroid  arteries, 
ligature  of,  in  enlarged  thyroid,  400;  of  superior  thyroid,  401  ;  of  inferior,  401; 
ulnar,  ligature  of,  in  the  forearm,  55;  in  lower  third,  56  ;  in  middle  third, -'6; 
vertebral,  ligature  of,  460,  463  ;  in  epilepsy,  462 

Artificial  anus,  formation  of,  658;  closure  of,  661 

Artificial  larynx,  383 

Aspiration  of  pleura,  513  ;  of  bladder,  778 

Astragalus,  excision  of,  952;  for  disease,  952;  for  infantile  paralvsis,  952  ;  for  injurv, 

952 
Axillary  aneurism,  amputation  at  siioulder-joint  for,  115 

Axillary  artery,  ligature  of,  first  part.  106;  of  third  part,  110;  old  operation,  110 ; 
rupture  of,  in  reduction  of  shoulder  dislocation,  112 

Bag,  for  distending  rectum  in  supra-pubic  cystotomy,  750 

Biliary  calculi,  removal  of,  708 

Bladder,  operations  on,  735;  removal  of  growths  from.  735;  removal  of  stone  from, 

740-774;  cystotomy,  774;  rupture  of,  775;  aspiration  of,  778 ;  puncture  of,  778  ; 

supra-pubic,  779  ;  per  rectum,  780;   through  the  prostate,  781 
Bone-crowns,  replacement  after  trephining,  168 
Bone-grafts,  restoration  of  humerus  by,  102 
Brachial  artery,  ligature  of,  at  bend  of  elbow,  91 ;  in  the  middle  of  the  arm,  92 ;  sijon- 

taneous  aneurism  of,  93 ;  abnormalities,  95 
Brain,  traumatic  abscess,  162,  183;  from  maNtoid  abscess,  195  ;  foreign  bodies  in,  198; 

removal  of  bullets  from,  198 ;  motor  area  of,  209  ;  tumors  of,  localization,  removal 

of,  216;  Prof.  Ilorsley's  method  of  operating  on,  227 


998  GENERAL   INDEX. 

Breast  cancer,  question  of  operation  in,  499;  removal  of,  499,  502;  chief  objects  in 
removal,  502;  recurrence  after  removal  of,  501;  need  of  extensive  operations 
for,  508  _ 

Bronchi,  foreign  bodies  in,  367 

Bullets  in  the  brain,  198 

C^SARIAN  section,  733 

Calculus,  biliary,  removal,  708;  renal,  evidence  of,  611;  conditions  simulating,  612; 

removal,  614;  in  bladder,  difficulties  in  finding,  741 ;  difficulties   in   extracting, 

748;  size  of,  suited  to  lateral  lithotomy,  749;  to  lithotrity  and  litholapaxy,  758; 

recurrence,  761  ;  detection  of  last  fragment  in  litholapaxy,  766 ;  treatment  of,  in 

the  female  bladder,  770 
Callus,  compression  of  musculo-spiral  nerve  by,  104 
Cancer,  see  different  parts,  e.g.,  for  cancer  of  tongue,  see  Tongue 
Garden's  amputation,  885 
Cardiac  orifice  of  stomach,  dilatation  of,  689 
Carotid,  common  ligature  of,  427,  438 ;   temporary  ligature,  438;  old  operation,  442 ; 

external,  ligature  of,  446,  453;  internal,  ligature  of,  455,  459 
Castration,  814,  818;  in  malignant  disease,  816;  in  tubercular  testis,  817 
Caustic  paste,  zinc  chloride,  use  of,  in  rodent  ulcer,  244 ;  after  removal  of  eyeballs,  252 ; 

after  clearing  out  orbit,  253;  after  removal  of  upper  jaw,  275,  300 
Cautery,  tracheotomy  by,  355 ;  in  removal  of  tongue,  338  ;  in  removal  of  the  penis,  804 
Cerebellar  abscess  from  ear  disease,  195,  196 
Cerebral  abscess,  from  foreign  bodies  in  the  skull,  162;  from  injury,  180;  from  ear 

disease,  195;  trephining  for,  196 
Cerebral  sinuses,  phlebitis  in  ear  disease,  197 
Cerebral  tumor,  localization  of,  209  ;  condition  of  skull  bones  in,  222 ;  varieties  of,  222  ; 

trephining  for,  216,  227 
Chest,  incision  of,  in  empyema,  516;  tapping  of,  511,  513;  nature  of  fluid  in,  serous 

or  purulent,  511 
Choice  of  operation    in    thoracic   aneurism.  498 ;    between    lumbar  and  abdominal 

nephrectomy,  639;  in  stricture-retention,  790;  between   excision   and  erasion  of 

the  knee,  909  ;  between  Syme's  and  Pirogoff''s  amputation,  943  ;  between  excision 

and  amputation  in  disease  of  the  tarsus,  951 
Cholecystectomy,  713 
Cholecystotomy,  708,  710 
Chopart's  amputation,  957 
Circular  amputation  of  arm,  100 ;  through  elbow-joint,  67  ;  of  forearm,  64 ;  penis,  801 ; 

thigh,  882;  wrist,  51 
Circumcision,  801 

Clamp  for  resection  of  intestine,  662;  in  piles  with  cautery,  823 
Clavicle,  wiring  ununited  fracture  of,  149;  removal  of,  146 
Clearing  out  of  orbit,  253 
Cleft  palate,  best  date  for  operation,  317;  operation  on  soft,  319;  on  hard,  321 ;  nasal 

flap  method,  323  , 

Closure  of  artificial  anus,  661 
Colectomy,  663 

Collateral  circulation  after  ligature,  see  each  artery 
Colon,  abnormalities  of,  603 
Colotomy,  lumbar,  591,  597  ;  choice  of  side  in,  593,  595;  aids  to  finding  bowel  in,  596; 

landmarks,  591,  597;  presence  of  mesocolon  in,  603;  by  two  stages,  600;  the  use 

of  pins  in,  600;  inguinal,  605;  inguinal  of  lumbar  in  imperforate  rectum,  606; 

comparison  of  colotomy  and  excision  of  the  rectum,  829 
Compound  depressed  fracture  of  skull,  operative  interference  in,  156;  compound  frac- 
tures, treatment  of,  934;  amputation  in,  936 
Condition  of  limb  after  hip-excision,  857  ;  of  patient  after  laryngectomy,  384 ;  after 

excision  of  rectum,  830 
Conical  trephine,  165 
Conservative  surgery  of  the  hand,  28 
Contracted  palmar  fascia,  operations  on,  32 
Cranial  bones  and  dura  mater,  growths  from,  152 
Cranial  bones,  condition  of,  in  cerebral  tumor,  222 
Crushing  of  piles,  824 
Curetting  gastric  cancer,  699 
Cystotomy,  774 


GENERAL   INDEX.  999 

Digital  dilatation  of  stoniacli  orifices,  687 

Dilatation  of  stomach  orifices,  687;  pylorus,  687;  cardiac  orifice,  689 

Direct  transfusion,  82 

Dislocation  of  shoulder,  rupture  of  axillary  artery  during  reduction,  112 

Distal  phalanx  of  finder,  amputation  of,  18 

Distance  sutures  in  union  of  tendons,  38 

Divided  tendons  of  fingers,  38  ;  nerves,  978 

Division  of  contracted  f>alniar  fascia,  32 

Dorsalis  pedis,  ligature  of,  938 

Drainage,  of  lung  cavities,  523;  value  of,  in  hydronephrosis,  607 

Dnodenostomy,  698 

Ear  disease,  phlebitis  of  cerebral  sinuses  in,  197;  meningitis  in,  197  ;  practical  ana- 
tomical points  in,  192;  mastoid  abscess,  193;  abscess  in  brain  or  cerebellum,  195. 

Ecraseur  in  the  removal  of  the  tongue,  337;  galvanic,  33S;  in  removal  of  bladder 
growths,  739 ;  in  removal  of  penis,  803 

Ectopia  vesicae,  796 

Elbow-joint,  amputation  through,  difl'erent  methods,  64;  excision  of,  67,  69;  arterio- 
venous aneurism  at  bend  of,  91 ;  conservative  surgery  in  gunshot  wounds  of,  96 

Electrolysis,  in  naso-pharyngeal  polypns,  281;  in  hydatids,  706 

Elephantiasis,  ligature  of  large  vessels  in,  531,  872 

Empyema,  514;  treatment  of,  515;  resection  of  ribs  for,  521 

Enterectomy,  663 

Enterotomy,  658;  right  iliac,  659 

Epispadias,  800 

Erasion  of  knee,  910 

Excision,  of  ankle,  947 ;  astragalus,  951 ;  elbow,  67 ;  hip,  854 ;  humerus,  101 ; 
hydrocele,  810;  knee-joint,  893;  pylorus,  691;  os  calcis,  953;  radius  and  ulna 
for  growths,  57 ;  in  military  surgery,  59 ;  rectum,  828;  shoulder,  126;  in  unre- 
duced dislocations,  128;  tarsal  bones  and  joints,  950;  teniporo-maxillary  joint, 
300 ;  wrist-joint,  40 

External  carotid,  ligature  of,  446 

External  iliac,  ligature  of,  532 

External  urethrotomy,  783 

Facial  artery,  ligature  of,  421 

Facial  nerve,  stretching  of,  236 

Female  bladder,  treatment  of  stone  in,  770 ;  by  dilatation  of  urethra,  770 ;  litholapaxy, 
771 ;  vaginal  lithotomy,  771 ;  supra-pubic  lithotomy,  773 

Femoral  artery,  common,  ligature  of,  866,  871  ;  question  of  ligature  of,  in  wound  of 
femoral  vein,  868;  question  of  ligature  of  common  femoral  or  external  iliac,  869 

Femoral  artery,  superficial,  ligature  of,  in  Scarpa's  triangle,  871,  873  ;  injury  to  femoral 
vein  during  operation,  875 ;  ligature  of,  in  Hunter's  canal,  875,  877 ;  wounds  of, 
875 

Femoral  hernia,  strangulated,  559 ;  operation  without  opening  the  sac,  560 ;  by  open- 
ing the  sac,  5ol ;  complications,  564 ;  wound  of  obturator  artery,  567  ;  radical 
cure  of,  589 

Femur,  ununited  fracture  of^  890 

Fifth  nerve,  operations  on,  230;  neurotomv,  230 ;  neurectomv,  fj31  ;  stretching  of, 
232,  235 

Fingers,  position  of  joints,  17;  practical  points  in  amputation,  17;  different  amputa- 
tion of  phalanges,  18  ;  theca,  IS  ;  amputation  of  distal  phalanx.  18 ;  of  second 
phalanx,  19  ;  through  middle  phalanx,  20;  at  metacarpo-phalangeal  joint,  22 ; 
removal  of  supernumerary,  24 ;  excision  of,  28  ;  reunion  of  severed,  30 ;    webbed,  30 

Fissure  of  rectum.  826 

Fissure  of  Rolando,  209;  modes  of  finding,  208,  211  ;  practical  points  in  application 
of  trephine  to,  214 

Fistula  in  ano,  varieties,  819;  in  phthisical  patients,  820;  operation,  821 

Fixity  of  lower  jaw,  300;  operations  for,  300 ;  excision  of  temporo-maxillary  joint, 
301 ;  Esmarch's  operation,  302 

Flap  methods,  see  different  operations 

Fore-arm,  amputation  of,  60 ;  practical  anatomical  points,  60;  methods,  60;  mixed, 
60;  transfixion,  62  ;  circular,  64  ;  bones  of,  excision,  57 


1000  GENERAL    INDEX. 

Foreign  bodies,  in  tlie  skull,  removal  of,  161 ;  in  the  brain,  operative  interference  in, 

198;  question  of  expectant  or  operative  treatment,  201,  203;  in  the  air  passages, 

removal  of,  366 
Fractures,  of  the  skull,  immediate  or  recent,  trephining  in,  156,  punctured,  160;  of 

inner  wall  of  orbit,  160;  compound,  treatment  of,  934;  question  of  amputation 

in,  936 
Frontal  sinuses,  trephining,  208 

Gall-bladder,  tapping  and  incising,  708  ;  removal  of  calculi  from,  711,  712 ;  removal 
of,  713   _         _ 

Gall-stones,  intestinal  obstruction  bv,  657  ;  when  justifying  operations  on  the  gall- 
bladder, 708,  709  ;  removal  of,  from  gall-bladder,  711,  712 

Galvanic  cautery,  in  removal  of  tongue,  338,  in  ara[)utation  of  the  penis,  804 

Gangrene,  amputation  at  shoulder-joint  for,  114;.  of  intestine  in  hernia,  565 

Gastroenterostomy,  697 

Gastrostomv,  comparison  of,  with  tubage  of  oesophagus,  677,  679  ;  method  of  Howse, 
680 

Gastrotomy,  685 

Glands,  enlarged  axillary,  question  of  cleaning  out,  508  ;  epithelioinatous,  in  tongue 
cancer,  334  ;  early  enlargement  of,  in  cases  of  growths  of  tonsil,  341  ;  enlarged,  in 
epithelioma  of  the  penis,  question  of  nature,  806 

Glutpeal  artery,  ligature  of,  551,  553  ;  old  operation,  554 

Growths,  enchondroma  of  thumb,  27  ;  myeloid,  of  radius  and  ulna,  57,  58;  malignant, 
of  axilla,  opening  axillary  artery,  106 ;  enchondroma  and  myeloid  growth  of  upper 
end  of  humerus,  128;  of  scapula,  138,  144;  of  clavicle,  146;  of  scalp,  151;  of  cra- 
nium and  dura  mater,  152;  of  brain,  216,  222;  parotid,  246;  of  eyeball,  250  ;  of 
orbit,  253;  of  jaw,  267,293;,  naso-pharyngeal,  278;  of  palate,  324;  of  tonsil,  340; 
of  larynx,  370  ;  thyroid,  385  ;  large  deep-seated,  of  the  neck,  407  ;-  of  kidney,  625  ; 
of  bladder,  736  ;  of  rectum,  828  ;  of  Scarpa's  triangle,  867  ;  of  testicle,  814 

Gunshot  injuries,  excision  of  wrist,  47  ;  excision  of  radius  and  ulna,  59;  excision  of 
elbow,  75 ;  ligature  of  brachial,  92  ;  excision  of  humerus,  101 ;  excision  of  shoulder, 
137;  removal  of  bullets  from  brain,  198;  of  abdomen,  operative  interference  in, 
666  5  of  hip,  859 ;  of  knee,  897 

HiEMORRHOiDS,  operations,  822 ;  ligature,  822  ;  clamp  and  cautery,  823;  crushing, 
823;  acid,  824;  Whiteiiead's  operation,  824 

Hard  palate,  openition  on  cleft  of,.  321 

Hare-lip,  best  time  for  operation,  303 ;  points  to  inquire  into  before  operating,  304; 
single,  305  ;  double,  310  ;  sudden  death  after  operations,  3U7  ;  treatment  of  pre- 
maxillary  bone,  310;  mortality  after,  313;  repetition  of  operation  for,  313 

Hepatic  abscess,  706 

Hepatotomy,  706 

Hernia,  strangulated.  558 ;  strangulated  femoral,  559  ;  operation  without  opening  the 
sac,  560 ;  with  opening  sac,  561 ;  complications  of  operation,  564;  strangulated 
inguinal,  508  ;  ai<ls  to  reduction  of  intestine,  570;  varieties,  572;  reduction  en 
masse,  573;  simulated  by  retained  testis,  573;  strangulated  umbilical,  574;  prac- 
tical points  before  operation,  574;  question  of  radical  cure,  576;  strangulated 
obturator,  577  ;  radical  cure,  578 ;  questionof  truss  after,  579;  different  operations, 
581  ;  Banks's,  582  ;  Macewen's,  584  ;  Barker's,  586  ;  Ball's,  587  ;  subcutaneous 
methods,  587  ;  Wood's,  587  ;  Spanton's,  588  ;  radical  cure  of  femoral  hernia,  589  ; 
radical  cure  of  umbilical,  590 

Hey's  amputation,  960 

Hip-joint,  amputation  at,  814,  848;  means  of  controlling  haemorrhage  during,  845 : 
Davy's  lever,  846;  Furneaux  Jordan's  method,  844;  flap  methods,  849  ;  lateral 
flaps,  852;  antero  external  and  postero-internal,  853;  excision,  854,  859  ;  chief 
questions,  854  ;  condition  of  limb  after,  857  ;  for  gunshot  injury,  859  ;  operation 
by  posterior  incision,  861  ;  by  anterior  incision,  863 

Hydatids  of  liver,  different  operations  for,  702;  puncture,  702  ;  incision,  704;  elec- 
trolysis, 702 

Hydrocele,  radical  cure  of,  807  ;  iodine  injection,  807  ;  antiseptic  incision,  809 ;  excision, 
810;  occasional  inveteracy  of,  811 

Hydronephrosis,  value  of  drainage,  624;  aspiration,  625;  nephrectomy,  625 


GENERAL    INDEX.  1001 

Iliac,  common,  ligature  of,  538,  545  ;  by  anterior  incision,  545;  posterior,  54G  ;  com- 
parison of  the  two  methods,  548 

Iliac  enterotomy,  right,  659 

Iliac,  external,  ligature  of,  528.  533,  535 

Iliac,  internal,  ligature  of,  548.  550;  by  laparotomy,  550 

Imperforate  anus,  835  ;  imperfectly  developed  rectum,  835;  inguinal  or  lumbar  colot- 
omy  in,  605 

Importance  of  tongue  ^-ancer,  325 

Incision  of  Wilde,  194;  of  empyema,  515  ;  of  hydatids  of  liver,  704  ;  of  hydrocele,  808 

Indian  method  of  rhinoplasty,  257 

Indirect  transfusion,  86 

Inflation  in  intussusception,  647 

Inguinal  hernia,  strangulated,  568 ;  reduction  of  intestine,  570;  causes  of  difficulty 
570;  aids,  570;  varieties,  572;  reduction  en  masse,  573;  radical  cure  of,  578 

Injection  of  hydrocele  with  iodine,  807 

Injuries  of  abdomen,  operative  interference  in,  666,  669 

Internal  iliac,  see  Iliac,  Internal ;  internal  carotid,  see  Carotid,  Internal 

Internal  urethrotomy,  791  ;  two  chief  modes,  793;  from  without  inwards,  793;  from 
within  outwards,  794;  comparison  of  tiie  two,  795 

Intestine,  reduction  of,  in  femoral  hernia,  562;  in  inguinal,  570;  difficulties  and  aids, 
570;  adhesions  of,  564;  different  conditions  of,  564 ;  acute  obstruction  of,  645  ; 
gunshot  injuries  of,  666  ;  resection  of,  664,  673,  674;  suture  of,  665 

Intussusce{)tion,  647;  replacement  by  inflition  or  injection,  647;  by  operation,  649 

Jaw,  lower,  fixity  of,  operations  for,  300;  excision  of  temporo-maxillary  joint,  301  ; 
Esmarch's  operation  of  removal  of  wedge,  302  • 

Jaws,  growths  of,  267,  394;  questions  arising  before  removal  of  upper,  271  ;  complete 
removal  of  upper,  273;  partial  removal  of  upper,  276  ;  operations  on  upper,  par- 
tial or  complete  removal,  or  osteoplastic  resection  for  naso-pliaryngeal  polypus, 
287  ;  antrum,  tapping,  293;  removal  of  lower,  293;  partial,  294;  of  half,  296  ; 
coniplete  removal  of  both  upper  jaws,  298  ;  question  of  gouging  or  removal  of  jaw, 
299 

Jejunostomw,  699 

Kidney,  operations  on,  610;  nephrotomy,  q.v.,  610;  nephro-lithotomy,  q.v.,  611; 
ne])lirectoniy,  q.v.,  623;  nephrorraphy,  q.v.,  642;  evidence  of  stone  in,  see  Eenal 
Calculus  and  Xephrodithotomy ;  importance  of  condition  in  deciding  on  opera- 
tion for  stone.  761 

Landmarks  in  colotomy,  597 

Laparotomy,  see  .■\bdoiniiial  Section 

Laryngectomy,  .see  Larynx,  Removal  of 

Laryngotomy,  346 

Larynx,  scalds  of,  365 ;  artificial,  383;  malignant  disease  of,  370;  removal  of,  370, 
375.  379;  mortality  after  removal,  372;  cures  due  to  operation,  372;  complete 
removal,  375;  date  of  preliminary  tracheotomy,  375;  tampon-cannulse,  376; 
partial  removal,  379;  condition  of  patients  after  removal  of  larynx,  384 

Lateral  lithotomy,  740 ;  with  the  curved  staff)  744;  with  the  straight  staff)  744;  in 
little  children.  745;  stones  suited  to,  749 

Leg,  amputation  of,  different  methods,  928  :  lateral  flaps,  928;  Teale's  method,  930 

Life,  duration  of,  in  cancer  of  breast  unoperated  upon,  500;  if  operated  on,  501 

Ligature  of  radial  on  back  of  wrist,  52  ;  in  forearm,  53  ;  idnar  in  forearm,  55 ;  brachial 
at  elbow,  91;  in  middle  of  arm,  92;  axillary,  105;  temporal,  419;  facial,  421; 
occipital,  421;  lingual,  424;  common  carotid,  427;  external,  446;  internal, 
455;  vertebral,  460;  subclavian,  second  and  third  parts,  465;  first  part,  475 ; 
iiuiominate,  477  ;  of  carotid  and  subclavian  in  thoracic  aneurism,  491 ;  external 
iliac,  52S;  common  iliac,  538;  internal  iliac,  548;  gluteal,  551;  sciatic,  555; 
abdominal  aorta,  555;  conmion  femoral,  866;  superficial  femoral  in  Scarpa's 
triangle,  871;  in  Hunter's  canal,  875;  popliteal,  917;  posterior  tibial,  920; 
anterior  tibial,  925;  dorsalis  pedi.s,  938;  of  naso-i)haryngeal  polypus,  282;  of 
ovarian  pedicle,  718;  of  cord  in  castration,  817;  of  hieniorrhoids,  822 

Linear  division  of  non-malignant  rectal  stricture,  591 

Lips,  operations  on,  303.  see  also  Hare-lip;  other  plastic  operations,  314;  restoration 
of  lower  lip,  339;  upper  lip,  323 


1002  GENERAL   INDEX. 

Lisfninc's  amputation,  960 

Litholapaxy,  758,  762;  contrasted  with  lithotrity,  767  ;  in  male  children,  769  ;  for 
stone  in  the  female,  770 

Lithotomy,  lateral,  740;  supra-pubic,  749 ;  median,  756;  in  the  female,  771;  com- 
pared with  lithotrity,  758 

Lithotrity,  choice  of  this  or  lithotomy,  758  ;  operation,  762  :  contrasted  with  lithotomy, 
767;  recurrence  of  stone  after,  761 

Littrfe's  operation,  605  ;  preferred  by  some  to  lumbar  colotomy,  607 

Liver,  operations  on,  702 

Loose  bodies  in  joints,  varieties,  916;  removal  from  knee-joint,  916 

Lumbar  colotomy,  591  ;  nephrectomv,  629;  choice  between  this  and  lumbar  operation, 
639      _ 

Lung  cavities,  drainage  of,  523 

Lupus,  operative  treatment  of,  240  ;  erasion,  241 ;  scarification,  242 

Mastoid  abscess,  anatomy  of  parts  concerned  in,  192;  symptoms,  193;  trephining 
mastoid  cells  for,  194 ;  abscess  in  brain  or  cerebellum  from,  195 

Median  lithotomy,  756 

Membranous  laryngitis,  tracheotomy  in,  348 

Meningeal,  middle,  see  Middle  Meningeal 

Meningitis  in  otitis  media,  197 

Mesocolon,  presence  of,  in  colotomy,  603 

Metacarpo-phalangeal  joint,  amputation  through,  22 

Metatarso-phalangeal  joint,  amputation  at,  963 

Middle  meningeal  haemorrhage,  175 

IMjlitary  surgery,  excision  of  wrist  in,  48  ;  of  radius  and  ulna,  59 ;  of  shaft  of  humerus, 
101;  of  shoulder,  137;  removal  of  bullets  from  brain,  198;  gunshot  injuries  of 
abdomen,  666;  haemorrhage  from  neck  after  gunshot  injuries,  436;  excision  of 
hip,  859;  excision  of  knee,  898 

Molluscum  fibrosum  of  scalp,  151 

Motor  area,  209 

Mouth,  restoration  of  angle  of,  317 

Movable  kidney,  operations  for,  642 

Musculo-spiral  nerve,  compressed  by  callus,  104 

Myeloid  growth  of  radius,  excision  of,  57;  of  ulna,  excision,  58;  of  upper  part  of 
humerus,  removal,  130;  nephrorraphy,  642;  nephrectomy,  645 

Myomata,  uterine,  725  ;  removal  by  abdominal  section,  725  ;  different  modes  of  treating 
pedicle,  727 

Myxoedema,  after  thyroidectomy,  390 

Nasal  polypi,  removal  of,  265 

Naso-pharyngeal  polyjjus,  methods  of  removal,  279  ;  avulsion,  279  ;  ligature,  280  ; 
galvanic  loop,  281;  electrolysis,  281;  removal  tlirough  moutii,  282;  tlirough 
nose,  285;  through  upper  jaw,  287 

Nephrectomy,  question  of,  during  nephro-lithotomy,  620;  for  malignant  diseases  of 
kidney,  625;  lumbar,  629;  abdominal,  through  the  peritoneum,  635  ;  Langenbeck's 
incision  at  outer  edge  of  rectus,  636;  incision  in  linea  alba,  637  ;  abdominal, 
without  opening  the  peritoneum,  638;  Konig's  free  lumbo-abdominal  incision, 
631 ;  treatment  of  kidney  pedicle,  632 

Nephro-lithotomy,  611,614;  evidence  of  renal  calculus,  611  ;  conditions  simulating 
renal  calculus,  612;  opei-ation,  614;  question  of  nephrectomy  during  nephro- 
lithotomy, 620 

Nephrorraphy,  642 

Nephrotomy,  611 

Nerve  stretching,  982 

Nerve  suture,  978 

Nerves,  operations  on,  fifth,  230;  neurotomy  and  neurectomy  of  first  division,  231 ;  opera- 
tions on  second  division,  232 ;  neurectomy,  Carnociian's  operation,  232 ;  operations 
on  third  division,  235;  nerve  stretcliing,  235;  intra-buccal  division,  236;  facial, 
stretcliing,  236;  suture,  978;  primary,  978;  secondary,  979;  stretching,  982 

Neurectomy  of  fifth  nerve,  231,  232 

Neurotomy  of  fifth  nerve,  231,  235 

Nose,  operations  on,  for  removal  of  naso-pharyngeal  polypus,  285 

Nose,  repair  of,  see  Rhinoplasty 


GENERAL   INDEX.  1003 

Obstruction,  site  of,  in  large  intestine,  593 ;  varieties  of,  in  acute  intestinal  obstruc- 
tion, 645 

Obturator  artery,  wound  of,  in  operation  for  femoral  hernia,  567 

Obturator  hernia,  strangulated,  577 

Old  operation  for  axillary  aneurism  and  ruptured  axillary,  110;  carotid,  442; 
common  iliac,  542  ;  glutseal,  554 

Olecranon,  ununited  fractui-es  of,  165 

Operative  interference  for  foreign  bodies  in  the  brain,  198  ;  treatment  of  lupus,  240  ; 
of  rodent  ulcer,  243;  of  suppurative  peritonitis,  660;  in  abdominal  injuries, 
666,  669 

Orbit,  fracture  of  inner  wall  cf,  160;  clearing  out  of,  253 

Orifices  of  stomach,  dilatation  of,  687 

Os  calcis,  excision  of,  953 

Osteotomy,  for  anchylosis  of  hip-joint,  964;  Adams',  through  neck  of  femur,  964; 
Gant's  infra-trochanteric,  965;  for  genu  valgum,  966;  of  femur  from  outer 
side,  966 ;  Macewen's  supra-condyloid,  967 ;  Ogston's  division  of  internal 
condyle,  969;  of  tibia  as  well  as  femur,  969;  of  tibia,  970;  simple,  971;  cunei- 
form, 971 ;  for  displacement  of  great  toe  in  bunion,  972 

Ostitis,  septic,  of  skull,  and  its  sequelae,  172 

Otitis  media,  results  of,  192,  194.     See  also  Mastoid  Abscess 

Ovariotomy,  questions  arising  before,  714;  operation,  716 

Palate,  soft  operation  for  closure  of  cleft,  319  ;  hard,  operations  on,  321 ;  growths 

of,  324 
Palmar  fascia,  contracted,  32 ;  hpemorrhage,  vessels  concerned,   36;  early  cases,  36 ; 

later,  37  ;  danger  of  inefficient  pressure,  38 
Papilloma  of  bladder,  735 

Paracentesis  of  thorax,  511,  513;  of  bladder,  778 
Parotid  growths,  246 

Partial  removal  of  scapula,  139;  larynx,  379;  thyroid,  394 
Patella,  ununited  fracture  of,  911 
Penis,  amputation  of,  803,804;  by  galvanic  cautery,  804;  circular,  804;  flap  method, 

804  ;  more  extensive  operations,  805 
Pericardium,  tapping  and  incising,  988 
Perineal  section,  783 

Perineum,  ruptured,  operations  for,  838  ;  partial  rupture,  838  ;  complete,  840 
Peritoneum,  limit  on  rectum,  828 

Peritonitis,  after  colotomy,  604 ;  suppurative,  operative  treatment  of,  660  ;  after  ovari- 
otomy, 721 
Peroneal  artery,  ligature  of,  928 

Phalanx,  distal,  of  finger,  amputation  of,  18 ;  middle,  amputation  through,  20 
Pliimosis,  neglected,  results  of,  801 
Phlebitis  of  cerebral  sinuses  in  ear  disease,  197 
Phthisical  patients,  fistula  in,  820 
Piles,  operations  on,  822;  ligature,  822;  acid,  824  ;  crushing,  824  ;  clamp  and  cauterv, 

823 
Pleuritic  serous  effusion,  512 

Polypus,  naso-pharyngeal,  operations  for,  285 ;  nasal,  265  ;  bladder,  736 
Poi)liteal  artery,  wound  of,  917  ;  ligature  of,  in  popliteal  space,  919  ;  from  the  front,  920 
Position  of  joints  in  fingers,  17 
Posterior  tibial  artery,  wounds  of,  920,  922;  ligature  in  middle  of  leg,  924;  in  lower 

third,  924;  at  inner  ankle,  925 
Pre- cancerous  stage  of  tongue  cancer,  325 
Pre-maxillary  bone,  treatment  of,  31 1 
Pressure,  value  of,  in  palmar  haemorrhage,  36;  in  punctured  wounds  of  thigh,  876; 

in  punctured  wounds  of  leg,  922 
Proctotomy,  591 

Prolapsus  of  rectum,  827  ;  application  of  acid  in,  827  ;  cautery,  827 ;  excision,  827 
Pulsating  tumor  of  pelvis,  simulating  aneurism,  543 
Puncture,  per  rectum,  780;    of  hydatids,  702;    of  bladder,  778;   supra-pubic,  779  ; 

through  prostate,  781 
Punctured  fractures  of  skull,  160 
Pus  between  skull  and  dura  mater,  169 
Pylorectomy,  691 
Pylorus,  dilatation  of,  687  ;  excision  of,  691,  693 ;  cancer  of,  treatment  by  curette,  700 


1004  GENERAL   INDEX, 

Questions  arising  before  removal  of  upper  jaw,  271 ;  removal  of  breast  cancer,  499  ; 
ovariotomy,  713;  exploration  in  acute  intestinal  obstruction,  651;  before  radical 
cure  of  umbilical  hernia,  576 ;  of  partial  removal  of  rectum,  833 

Radial  artery,  ligature  of,  on  back  of  wrist,  52  ;  in  forearm,  54 

Radical  cure  of  hernia,  578  ;  question  of  use  of  truss  after,  579 ;  different  methods, 
580;  method  of  Banks,  582;  Macewen's,  584;  Barker's,  586 ;  Ball's,  by  torsion 
of  the  sac,  589  ;  subcutaneous  methods,  587  ;  Wood's,  587  ;  Spanton's,  588  ;  injec- 
tion of  astringents,  5S9;  of  femoral  hernia,  589;  of  umbilical,  5!)0  ;  of  hydrocele, 
807;  injection,  807  ;  incision,  809;  excision,  810;  occasional  difficulty,  811 

Radio-ulnar  (superior)  joint,  excision  of,  77 

Radius,  excision  of  myeloid  growth  of,  96  ;  excision  in  military  surgery,  59 

Rectal  bag,  750 

Recto-vesical  fistula,  detection  of,  593  ;  colotomy  for.  593 

Rectum,  fistula,  819;  pile  area,  824;  prolapsus,  827  ;  excision,  828 ;  comparison  be- 
tween excision  and  colotomy,  829;  removal  of  complete  circumference,  831; 
question  of  partial  removal,  833  ;  imperfectly  developed,  835 ;   varieties,  835 

Recurrence  of  cancer  after  breast  removal,  501 ;  of  stone  after  lithotrity,  761 

Reduction,  of  intestine  in  hernia,  aids,  570;  en  masse,  573 

Re-infusion,  89 

Removal  of  scapula,  138;  partial,  139;  complete,  141;  complete,  together  with  upper 
extremity,  144 ;  of  clavicle,  146;  of  parotid  growths,  246;  nasal  polypi,  265; 
upper  jaw,  267;  naso-pharyngeal  polypus,  278  ;  half  of  lower  jaw,  296;  tongue, 
325  ;  tonsil  growths,  340 ;  tube  after  tracheotomy,  357  ;  thyroid  gland,  385  ;  deep- 
seated  growths  in  the  neck,  407;  breast,  499;  biliary  calculi,  710,  712;  gall- 
bladder, 713;  ovarian  tumor,  713;  uterine  appendages,  721  ;  cancerous  uterus, 
by  vagina,  730;  by  abdominal  section,  730;  growths  of  the  bladder,  735;  rectum, 
828;  loose  bodies  from  knee-joint,  916  ;  exostosis  from  adductor  tubercle,  889 

Renal  calculus,  evidence  of,  611 ;  conditions  simulating,  612  ;  removal,  614 

Repair  of  nose,  see  Rhinoplasty  ;  of  lips,  see  Lips;  of  Perineum,  see  Perineum 

Resection  of  rilDS,  520 

Restoration  of  lips,  314;  of  angle  of  mouth,  317  ;  of  Steno'sduct,  239  ;  of  perineum,  838 

Retained  testis,  simulating  strangulated  hernia,  573;  castration  for,  817 

Re-union  of  severed  digits,  30;  tendons,  38  ;  nerves,  978 

Rhinoplasty,  254;  complete,  255 ;  partial,  263  ;  Verneuil's,  255;  Syme's,  256;  frontal 
or  Indian,  257  ;  Italian  or  Tagliacotian,  261 

Ribs,  resection  of,  for  caries,  520 ;  empyema,  520  ;  rudimentary  last  rib,  614 

Rodent  ulcer,  operative  treatment  of,  243 

Rolando,  fissure  of,  209 

Rouge's  operation,  264 

Rudimentary  last  rib,  importance  in  kidney  operations,  614 

Rupture  of  axillary  artery  in  shoulder  dislocations,  112;  intestine,  666  ;  of  bladder, 
775;  of  urethra,  781;  of  perineum,  838 

Sac,  hernial,  aids  in  recognizing,  561 

Saline  solutions  for  transfusion,  88 

Scalds  of  larynx,  365 

Scalp,  operations  on,  mode  of  arresting  hsemorrhage,  151  ;  new  growths  of,  151 

Scapula,  removal  for  growths,  138  ;  partial  removal,  139;  complete,  141  ;  together  with 
upper  extremity,  144  ;  removal  for  caries,  146 

Scarification  in  lupus,  242 

Sciatic  artery,  ligature  of,  555 

Scissors  operation  on  tongue,  327 

Sequestrotomy,  932 

Serous  pleuritic  effusions,  512 

Severed  digits,  reunion  of,  30 

Shoulder-joint,  rupture  of  axillary  artery  in  dislocations,  112;  amputation  of,  113;  for 
subclavian  aneurism,  114;  different  means  of  arresting  hfemorrhage,  117  ;  lateral 
flaps,  118;  Spence's  method,  120;  superior  and  inferior  flap<,  122;  deltoid  flap, 
124;  anterior  and  posterior  flaps,  121;  excision  of,  123;  for  enchondroraa,  128; 
for  myeloid  disease,  130;  by  straight  incision,  131 ;  by  deltoid  flap,  131  ;  site  of 
bone  section,  13-1 ;  sub-periosteal  resection,  135  ;  excision  in  military  surgery,  137 

Simple  depressed  fractures  of  skull,  157 

Single  hare-lip,  305 


GENERAL   INDEX.  1005 

Sinuses,  venous,  of  skull,  injury  to,  159 ;  frontal,  trephining,  208 

iSkey's  amputation,  960 

Skull,  depressed  fracture,  operative  interference  in,  156 ;  septic  ostitis  and  its  sequelae, 
172;  punctured  fractures  of,  160;  venous  sinuses  of,  injury  to,  159;  tumors  of, 
152;  spiculation  of  inner  table,  158  ;  removal  of  foreign  bodies  from,  161  ;  posi- 
tion of  obief  sutures  in,  211  ;  trephining  in  immediate  or  recent  fractures  of,  157; 
bones  of,  condition  in  cerebral  tumors,  222 

Soft  palate,  operation  on,  319 

Spina  bifida,  operations,  985;  injection  with  Morton's  fluid,  985;  tapping  and  drain- 
age, 986  ;  excision  of  the  sac,  986 

Spinal  accessory  nerve,  operations  on,  417 

Spleen,  excision  of,  700 

Steno's  duct,  restoration  of,  239 

Stomach  orifices,  dilatation  of,  687 

Stone  in  the  kidney,  see  Renal  Calculus;  in  the  gall-bladder,  see  Biliary  Calculi;  in 
the  bladder,  see  Lithotomy  and  Litholapaxy 

Strangulated  hernia,  femoral,  559;  inguinal,  568;  umbilical,  574;  obturator,  577 

Stretching  fifth  nerve,  232,  235 ;  inferior  dental,  235  ;  facial  nerve,  236 ;  great  sciatic, 
984 

Stricture,  of  rectum,  with  reference  to  colotomy,  591  ;  with  reference  to  excision,  828; 
of  oesophagus,  677  ;  of  urethra,  choice  of  operation  in  retention,  790;  in  relation 
to  urethrotomy,  795 

Sub-astragaloid  amputation,  946 

Subclavian,  ligature  of,  second  and  third  parts,  467  ;  first  part,  475 

Sub-periosteal  excision,  value  of,  in  elbow-joint,  69;  in  shoulder-joint,  135;  in  tarsal 
disease,  951 

Superior  radio-ulnar  joint,  excision  of,  77 

Supernumerary  fingers,  removal  of,  24 

Suppurative  peritonitis,  658 

Supra-pubic  lithotomy,  749,  753 ;  question  of  suturing  the  bladder,  754 

Supra-pubic  puncture  of  bladder,  779 

Sutures,  plaited  twist  silk,  404;  button,  507  ;  Lembert's  method,  665 

Syndesmotomy,  974 

Tagliacotian  rhinoplasty,  261 

Talipes,  removal  of  wedge  from  tarsus  for,  956;    tenotomy  for,  973;    syndesmotomv, 

974 
Tampon  cannula,  377 
Tarsus,  practical   points  before  operation,  950;    removal  of  many  tarsal   bones,  954  ; 

operation  of  Mickulicz,  954;  of  H.  P.  Watson,  955;  excision  of  wedge  for  talipes, 

956 
Temporary  ligature  of  common  carotid,  250 
Temporo-maxillary  joint,  excision  of,  300 

Tendons,  divided  suture  of,  38;  transplantation  in,  39;  surrounding  wrist,  41 
Tenotomy,  973  ;  of  tibial  tendons,  973:  of  plantar  fascia,  974;  syndesmotomy,  974;  of 

tendo-Achillis,  976  ;  of  hamstrings,  976  ;  of  sterno-mastoid,  977 
Testicle,  growths  of,  814;  tubercular,  817  ;  syphilitic,  817  ;  old  hsematoceie,  817  ;  rarer 

indications  for  castration,  817  ;  retained,  simulating  strangulated  hernia,  573 
Tetanus,  tracheotomy  in,  364 
Theca  of  fingers,  18 
Thompson's  fluid,  751 

Thumb,  amputation  of  phalanges,  25  ;  at  carpo-metacarpal  joint,  25;  excision  of,  27 
Thyroid  arteries,  ligature  of,  400;  superior,  401  ;  inferior,  401 
Thyroid  gland,  sudden  suflbcation  from   enlarged,  386 ;    removal  of,  eflfects  of,  390; 

theories   explaining   myxcedema,  391 ;    removal  of  one-half,  394;  operations  on 

isthmus,  398;  ligature  of  thyroid  arteries,  400;  thyroid  cysts,  402 
Thyrotomy,  344 
Tongue  cancer,  importance  of  pre-cancerous  stage  in,  325  ;  microscopical  examination 

of  ulcer,  325 ;    questions  arising  before  removal,  326;    removal  by  Whiteiiead's 

metliod,  328;  preliminary  laryngotomy,  329;  slitting  the  cheek,  333  ;  ligature  of 

the  Unguals,  333;  Syme's  methods,  334;  Kocher's,  335;  ^craseur,  337  ;  galvanic, 

338 
Tonsil,  removal  of  growths  of,  340;  through  the  mouth,  341  ;  through  the  neck,  342; 

Cheevers's  method,  342;  Czerny's  method,  343;  Mickulicz's  method,  344 


1006  GENERAL    INDEX. 

Tracheotomy,  for  membranous  laryngitis,  348 ;  influence  of  age,  348  ;  right  time  for 
operating  and  selection  of  cases,  349;  operation,  351,  352;  method  of  Eose,  355; 
by  tiierino-caiitcre,  355 ;  after-treatment,  356;  removal  of  tube  after,  357  ;  for 
tetanus,  364;  aortic  aneurism,  364;  tubercular  and  syphilitic  ulceration,  363; 
malignant  disease  of  larynx,  364  ;  acute  laryngitis,  364  ;  scalds  of  larynx,  365; 
before  excision  of  lai'ynx,  375 

Transfusion,  direct, 82;  Galabin's  method,  83;  Aveling'sandCripps's, 84;  Roussel's, 86 ; 
indirect,  86  ;  solutions  other  than  blood,  88  ;  re-infusion,  89  ;  arterial  transfusion,  90 

Transplantation  of  bone-grafts,  102 

Traumatic  epilepsy,  185;  trephining  for,  187  ;  removal  of  brain  scar  for,  188 

Trephine,  conical,  165 

Trepiiining,  compound  depressed  fractures,  156  ;  simple  depressed  fractures,  157  : 
fractures  of  inner  wall  of  orbit,  160  ;  for  removal  of  foreign  bodies  fi'om  skull,  161 ; 
operation,  163;  precautions,  166;  for  pus  between  bone  and  dura  mater,  169,  171  ; 
for  middle  meningeal  haemorrhage,  175, 178  ;  for  exploi-ation  of  traumatic  cerebral 
abscess,  180,  183;  for  later  results  of  cranial  injuries,  epilepsy,  etc.,  185,  187  ;  mas- 
toid abscess,  192,  194;  cerebral  and  cerebellar  abscess  due  to  otitis  media,  195  ; 
removal  of  foreign  bodies  from  brain.  198,  201,  202;  removal  of  cerebral  tumors, 
209,  216,  219,  221,  223,  224,  225;  Professor  Horsley's  method,  227  ;  in  Carnochan's 
operation,  232;  frontal  sinuses,  208  ;  vertebral  canal,  987 

Tubercular  tumors  of  brain,  221 ;  of  testis,  castration  for,  816 

Ulcer  of  the  tongue,  importance  of  microscopical  examination,  325 ;  of  rectum,  826 

Ulna,  excision  of  myeloid  growth  of,  58  ;  excision  in  gunshot  injuries,  59 

Ulnar  artery,  ligature  of,  55;  in  lower  third,  56  ;  in  middle  third,  56 

Umbilical  hernia,  strangulated,  574 ;  question  of  radical  cure  of,  576 ;  radical  cure  of, 

590 
Unilateral  laryngectomy,  381 ;  removal  of  thyroid  gland,  393 
Ununited  fracture  of  olecranon,  77;  clavicle,  149;  femur,  890;    patella,   911 
Upper  jaw,  growths  of,  questions  arising  before  removal,  271  ;  complete  removal,  273; 

partial,  276;  for  removal  of  naso-pharyngeal  polypus,  287 
Upper  lip,  restoration  of,  316 
Urethra,  ruptured,  781 
Urethrotomy,  external,  783  ;  Syme's,  783  ;  Wheeihouse's,  784 ;  Cock's,  787  ;  internal, 

791  ;  from  without  inwards,  793;  from  within  outwards,  794 
Uterine  myomata,  removal  of,  by  abdominal  section,  725 ;  treatment  of  pedicle  by  wire 

loop,  727  ;  clamp,  728  ;  forcipressure,  728;  elastic  ligature,  729 
Uterus,  cancerous,  removal  of,  by  abdominal  section,  729;   by  vagina,  730 

Vaginal  lithotomy,  772 

Varicocele,  811 

Varieties  of  inguinal  hernia,  572;    bladder  growths,  735;    growths  of  jaws,  267,  293; 

loose  bodies  in  joints,  916 
Vein,  axillary,  removal  of  part  of,  507 
Venesection,  79 
Vertebral  canal,  trephining,  987 

Webbed  fingers,  30;  Norton's  operation  for,  31  ;  Didot's,  31 

Wiring  ununited  fractures,  of  olecranon,  77  ;  patella,  893  ;  bones  in  Pirogoff's  ampu- 
tation, 945 

Wound  of  palm,  36 ;  obturator  artery,  567  ;  punctured  and  incised,  of  thigh,  876  ;  leg, 
920,  921  ;  see  also  Arteries 

Wrist-joint,  tendons  surrounding,  42;  excision,  40;  Sir  J.  Lister's  method,  42  ;  West's, 
45  ;  by  single  dorsal  incision,  45;  for  injury,  47  ;  for  gunshot  injury,  47  ;  amputa- 
tion at,  49  ;  diflerent  methods,  49  ;  palmar  flap,  49 ;  equal  antero-posterior  flaps, 
51 ;  Dubreuil's  method,  51 ;  circular,  49  ;  Teale's,  49 


CATALOGUE 
No.  1. 


JANUARY,  1891. 

CATALOGUE 


OF 


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WITH  A  SUBJECT  INDEX, 

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Gould's  New  Medl.    y^  Lea., 

3.25:  y2  M.  Thumb  Index.  4.25 
Harris'  Dental.  Clo.  6.50 ;  Shp.  7.50 
Longley's  Pronouncing  -  i.oo 

Maxwell.  Terminologia  Med- 
ica Polyglotta.  -        -        4.00 
Treves.     German  English.        3.75 

DIRECTORY. 
Medical,  of  Philadelphia,     2.50 

EAR. 
Burnett.     Hearing,  etc.  .50 

Jones.     Aural  Surgery.     -  2.75 

Pritchard.     Diseases  of.  1.50 

ELECTRICITY. 
Althaus'  Text  Book.         -        6.00 
Mason's  Compend.  -        i.oo 

EYE. 
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Fox  and  Gould.  Compend.  i.oo 
Gower's  Ophthalmoscopy.  5.50 
Harlan.     Eyesight.  -  .50 

Hartridge.  Refraction.  4thEd.  2.00 
Higgins.     Practical  Manual.    1:75 

Handbook,  -  .50 

Liebreich.    Atlas  of  Ophth.    15.00 


Macnamara.     Diseases  of.     % 

Meyer  and    Fergus.      Com- 
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Monthly.  -  3.00 

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HEADACHES. 
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HEALTH  AND  DOMESTIC 
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Burnett.     Hearing.  -  .50 

Cohen.  Throat  and  Voice.  .50 
Dulles.  Emergencies.  3d  Ed.  .75 
Harlan.     Eyesight.  -  .50 

Hartshorne.  Our  Homes.  .50 
Hufeland.     Long  Life.    -  i.oo 

Lincoln.     Hygiene.  -  .50 

Osgood.  Dangers  of  Winter.  .50 
Packard.    Sea  Air,  etc.  .50 

Richardson's  Long  Life.  .50 

Tanner.     On  Poisons.      -  .75 

White.  Mouth  and  Teeth.  .50 
Wilson.  Summer  and  its  Di;.  .50 
Wilson's  Domestic  Hygiene,  i.oo 
Wood       Brain  Work.      -  .50 

HEART. 

Fothergill.     Diseases  of.  3.50 

HISTOLOGY. 

See  Microscope  and  Pathology. 

HYGIENE. 

Frankland.     Water  Analysis,  i.oo 

Fox.     Water,  Air,  Food.  4.00 

Lincoln.     School  Hygiene.         .50 

Parke's  fE.)  Hygiene.  7th  Ed.  4.50 

(L.  C.),  Manual.  2.50 

Starr.  Hygiene  of  the  Nursery,  i.oo 
Wilson's  Handbook  of.  -  

Domestic.     -        -  i.oo 

JOURNALS,  Etc. 

Archives  of  Sprgery.  4  Nos.  3.00 
Jl.  of  Dermatology.  "  "  3.00 
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New  Sydenham  Society's 

Publications     ...        g.oo 

KIDNEY  DISEASES. 
Beale.     Renal  and  Urin.  1.75 

Edwards.     How  to  Live  with 

Bright's  Disease.    -         -  .50 

Ralfe.  Dis.  of  Kidney,  etc.  2.75 
Thornton.  Surg,  of  Kidney.  1.75 
Tyson.     Bright's   Disease 

and  Diabetes,  lllus.  -        3.50 

LIVER. 

Habershon.     Diseases  of.         1.50 

Harley.     Diseases  of      -  3.00 

LUNGS  AND  CHEST. 

See  Phy.  Diagnosis  and  Throat. 

Hare.     Mediastinal  Disea.se.     2,00 

Harris.     On  the  Chest.   -  2.50 

Williams.    Consumption.        5.00 

MASSAGE. 
Murrell.     Massage.  5th  Ed.     1.50 
Ostrom.     Massage.     lllus,         .75 

MATERIA  MEDICA. 
Biddle.     nth  Ed.  Clo.  4.25 

Gorgas.  Dental,  3d  Ed,  3.50 
Merrell's  Digest,  -  4.00 

Potter's  Compend  of.  5th  Ed.  i  co 


CLASSIFIED  LIST  OF  P.  BLAKISTON,  SON  &-  CO:S  PUBLICATIONS. 


Potter's  Handbook  of.  Second 
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Roberts'  Compend  of.  2.co 

MEDICAL  JURISPRUDENCE. 

Reese.   Medical  Jurisprudence 
&Toxicology,2d  Ed.  3.oc;bh  3.50 
MICROSCOPE. 

Beale.     How  to  Work  with.     7.50 

In  Medicine.         -  7.50 

Carpenter.     The  Microscope. 

Lee  Vade  Mecum  of.  2cl  Ed.  4.00 
MacDonald.     E.xamination  of 

Water  by.        -        -        -  2.75 

Wythe.     The  Microscopist.     3.00 

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Beale.      Slight  Ailments.  1.25 

Black.     Micro-organisms.  1.50 

Crookshank.  Vaccination.  8.50 
Davis,  iext-book  of  Biology.  4.00 
Duckworth.     On  Gout.  -  700 

Edwards.     Vaccination.  .50 

Garrod.  Rheumatism,  etc.  6.00 
Gross.  Life  of  John  Hunter.  1.25 
Haddon.  Embryology.  -  6.00 
Henry.     Anaemia.    -  .75 

Keating.  Lile  Insurance.  Net,  2.00 
MacMunn.  The  Spectroscope  3.00 
Madden.     Health  Resorts.       2  50 

NERVOUS  DISEASES,  Etc. 
Flower.    Atlas  of  Nerves.         3.50 
Bowlby.     Injuries  of.        -        4.50 
Gowers.    Manual  of.     i  vol. 

341  Illustrations.  -      

Dis.  of  Spinal  Cord.      

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Osier.     Cerebral  Palsies.  2.00 

Page.     Injuries  of  Spine.  

Radcliffe.  Epilepsy,  Pain,  etc.  1.25 
Thorburn.      Surgery    of    the 

bpinal  Cord    -        -        .  4.50 

Watsofi.     Concussions.  i.oo 

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Monthly    Nursing.  .50 

Domville's  Manual.  6th  Ed.  .75 
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Stair.  Hygiene  of  the  Nursery.  I.oo 
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Barnes.  Obstetric  Operations.  3.75 
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Galabin's  Manual  of.  3.00 

Glisan's  I'e.xt-book.  2d  Ed.  4.00 
Landis.  Compend.  4  h  Ed.  i.oo 
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Rigby.     Obstetric  Mem.  .50 

Strahan.  E.xtra-Uterine  Preg.  1.50 
Tyler  Smith's  Treatise.  4.00 

Swayne's  Aphorisms  gth  Ed.  1.25 
Winckel's  Text-book.  \  6.00 
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Bowlby.     Surgical  Path.  2.00 

Gibbes.    Practical.  -  1.75 

Gilliam.     Essentials  of.  -  2.00 

Stirling's  Practical.         -  4.00 

Virchow.     Post-mortems.         i.oo 

Cellular   Pathology.      4.00 

Wynter&  Wethered.  Path.  4.00 

PHARMACY. 
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formulary.      -        -  2.25 

Fliickiger.  Cinchona  Barks.  1.50 
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Mackenzie.   Phar.  of  Throat    1.25 


Merrell's  Digest.     -        -       $4.00 
Proctor.     Practical  Pharm.      4.50 
Robinson.  Latin  Grammar  of.  2.00   1 
Stewart's  Compend.  2d  Ed.     i.oo 
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PHYSIOLOGY. 
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trated.    4th  Ed.      -        -  I.oo 
Kirkes'   12th    Ed.     (Author's 

Ed.)  Cloth,  4.00;   Sheep,  5.00 

Landois'  Text-book.  583  Illus- 
trations.    2d  Ed.      -         -        6.50 
Sanderson's  Laboratory  B'k.  5.00 
Sterling.     Practical  Phys.         2.25 
Tyson's  Cell  Doctrine.    -  2.00 

Yeo's  Manual.  321  Illustrations 
4th  Ed     Cloth,  3.00;  Sheep,  3.50 
POISONS. 
Aitken.    The  Ptomaines,  etc.    1.25 
Black.     Formation  of.      -  i  50 

Reese.  Toxicology.  2d  Ed.  3.00 
Tanner.     Memoranda  of.  .75 

PRACTICE. 
Beale.     Slight  Ailments.  1.25 

Fagge's  Practice.  2  Vols.  8.00 
Fenwick's  Outlines  of.    -  1.25 

Fowler's  Dictionary  of. 
Hughes.  Compend  of.  2  Pts.  2.00 

Physicians'  Edition. 

I  Vol.  Morocco,  Gilt  edge.  2.50 
Roberts.  Text-book.  Sth  Ed.  5.50 
Tanner's  Index  of  Diseases.  3.00 
Taylor's  Manual  of.     -  4  00 

PRESCRIPTION  BOOKS. 
Beasley's  3000  Prescriptions.   2.25 

Receipt  Book.        -  2.25 

Formulary.     -         -  2.25 

Pereira's  Pocket-book.  i.oo 

Wythe's  Dose  and  Symptom 

Book.     17th  Ed.     -         -  I.oo 

SKIN  AND  HAIR. 
Anderson's  Text-Book.  4.50 

Bulkley.    The  Skin.        -  .50 

Crocker.  Dis.  of  Skin.  lUus.  5.50 
Van   H%rlingen.      Diagnosis 

and  Treatment  of  Skin  Dis. 

Col.  Plates  &  Engravings.  2.50 
STIMULANTS  &  NARCOTICS. 
Lizars.     On  Tobacco.      -  .50 

Miller.      On  Alcohol  .50 

Parrish.     Inebriety.         -  1.25 

SURGERY   AND   SURGICAL 

DISEASES. 
Caird  and  Cathcart.     Surgi- 
cal Handbook.  Leather,  2.50 
Dulles.     Emergencies.         -        .75 
Heath's  Operative.  -        12.00 

Minor.    9th  Ed.       -  2.00 

Diseases  of  Jaws.  4.50 

Lectures  on  Jaws.  i.oo 

Horwitz.    Compend.   3d  Ed.    i.oo 
Jacobson.     Operations  of    -     5.00 
Porter's    Surgeon's    Pocket- 
book.  -        -     Leather.  2.25 

Roberts.     (A.  S.)  Club-Foot.     .50 

(A.  S.)    Bow-Legs.  .50 

Smith.  Abdominal  Surg.  7.00 
Swain.  Surg.  Emergencies.  1.50 
Walsham.  Practical  Surg.  3  00 
Watson's  Amputations.  5.50 

TECHNOLOGICAL  BOOKS. 

See  also  Chemistry. 

Cameron.     Oils  &  Varnishes.  2.50 

boap  and  Candles.         2.25 

Gardner.     Brewing,  etc.  1.75 

Gardner.     Acetic  Acid,  etc.      1.75 

Bleaching  &  Dyeing.     1.75 

Groves  and  Thorp.  Chemi- 
cal Technology.  Vol.  I. 
Millson  Fuels.  CI.  7.50;  J^M.  9.C0 

I.oo 
I.oo 


Overman.     Mineralogy. 
Piggott.     On  Copper. 

THERAPEUTICS. 
Biddle.  nth  Ed.  CI.  4.25;  Sh. 
Cohen.     Inhalations. 


5.00 
1.25 


Field.  Cathartics  and  Emetics. | 
Headland.    Action  of  Med. 
Kirby.     Selected  Remedies. 
Mays.     Therap.  Forces. 

Theiiie         .        -        . 

Ott.     Action  of  Medicines. 
Potter's  Compend.     5th  Ed. 

,  Handbook  of.  4.00  ;  Sh. 

Starr,  Walker  and  Powell. 

Phys.  Action  of  Medicines. 
Waring's  Practical.    4th  Ed. 

THROAT  AND  NOSE. 
Cohen.     Throat  and  Voice. 

Inhalations. 

Greenhow.     Bronchitis. 
James.     Sore  Throat 
Journal  of  Laryngology. 
Mackenzie.  The  (£sophagus, 

Naso-Pharyn.x,  etc. 

Pharmacopoeia.    - 

Murrell.     Bronchitis. 
Potter.     Stammering,  etc. 
Woakes.  Post-Nasal  Catarrh. 

Nasal  Polypus,  etc. 

Deafness,  Giddiness,  etc. 

TRANSACTIONS  AND 

REPORTS. 

Penna.  Hospital  Reports.      1.15 

Power  and  Holmes'  Reports.   1.25 

Trans.  College  of  Physicians.  3.50 

Amer.  Surg.  Assoc.        3.00 

Assoc.  Amer.  Phys.   3.50 

URINE  &  URINARY  ORGANS. 
Acton.     Repro.  Organs.  2.00 

Beale.     Urin.  &  Renal  Dis.      1.75 

Urin.  Deposits.    Plates.  2.00 


75 
3.00 

•50 
1.25 
1-25 
1.25 
3.00 

3.00 
1.25 
1.50 
I.oo 
1.50 
1.25 


Holland.  The  Urine  and  Com- 
mon Poisons.     3d  Ed.      -        i.oo 
Legg.     On  Urine.     -        -  .75 

MacMunn.  Chem.  of  Urine,  3.00 
Marshall  and  Smith,  Urine,  i.oo 
Ralfe.  Kidney  and  Uri.  Org.  2.75 
Schnee.      Diabetes.  -        2.00 

Thompson.  Urinary  Organs.   3.50 

Surg,  of  Urin.  Organs.    1.25 

Calculous  Dis.  3d.  Ed.    i.oo 

Lithotomy.     -        -  3.50 

Prostate.     6th  Ed.  2.00 

Thornton.  Surg,  of  Kidney.  1.75 
Tyson.  Exam,  of  Urine.  1.5U 
Van  Niiys.    Urine  Analysis.     2.00 

VENEREAL  DISEASES. 
Cooper.     Syphilis.  -        -  3.50 

Durkee.     Gonorrhoea.     -  3.50 

Hill  and  Cooper's  Manual,  i.oo 
Lev/in.     Syphilis.  Pa  75;  Clo.  1.25 

VETERINARY. 
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Ballou.     Anat.  and  Phys.  i.oo 

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VISITING   LISTS. 
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Monthly  Ed. 

Plain,  .75;  Tucks,  i.oo 
WATER. 
Fox.     Water,  Air,  Food.  4  00 

Frankland.     Analysis  of.  i.oo 

Leffmann  &  Beam.  Exam.  of.  1.25 
MacDonald.     Analysis  of        2.75 

WOMEN,  DISEASES  OF. 
Byford's  Text-book.  4th  Ed.   5.00 

Uterus.  .        -         -  1.25 

Dillnberger.  and  Children.  1.50 
Doran.  Gyna;c.  Operations.  4.50 
Edis.     Sterility.         -        -  1.75 

Lewers.  Dis.  of  Women.  2.25 
Morris.     Compend.  -  i.oo 

Scanzoni.  Sexual  Organs  of.  4.00 
Tilt.     Change  of  Life.      -  1.25 

Winckel,  by  Parvin.    Manual 
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From  PROF.  J.  M.  DaCOSTA. 

"  I  find  it  an  excellent  work,  doing  credit  to  the  learning  ani  discrimination  of  the  author.' 


A  New  Medical  Dictionary. 


A  compact,  concise  Vocabulary,  including 
all  the  Words  and  Phrases  used  in  medicine, 
with  their  proper  Pronunciation  and  Defini- 
tions. 

BASED  ON  RECENT  MEDICAL 
LITERATURE. 

BY 

GEORGE  M.  GOULD,  A.B.,  M.D., 

ophthalmic  Surgeon  to  the  Philadelphia  Hospital,  Clinical 
Chiefi  Ophthnhnological  Dcpt.    German  Hos- 
pital, Philadelphia. 

It  is  not  a  mere  compilation  from  other 
dictionaries.  The  definitions  have  been 
made  by  the  aid  of  the  most  recent  stan- 
dard text-books  in  the  various  branches  of 


Small  8vo,  Half  Morocco,  as  above,  with 

Thumb  Index, $4.25 

Plain  Dark  Leather,  without  Thumb  Index,    3.25    medicinC.       It  includes 


SEVERAL  THOUSAND  NEW  WORDS  NOT  CONTAINED  IN 
ANY   SIMILAR  WORK. 

IT  CONTAINS  TABLES  of  the  ABBREVIATIONS  used  in  Medicine,  of  the 
ARTERIES,  of  the  BACILLI,  giving  the  Name,  Habitat,  Characteristics,  etc.;  of  GAN- 
GLIA, LEUCOMAINES,  MICROCOCCI,  MUSCLES,  NERVES,  PLEXUSES, 
PTOMAINES,  with  the  Name,  Formula,  Physiological  Action,  etc.;  and  the  COMPARI- 
SON OF  THERMOMETERS,  of  all  the  most  used  WEIGHTS  AND  MEASURES 
of  the  world,  of  the  MINERAL  SPRINGS  OF  THE  U.  S.,  VITAL  STATISTICS, 
etc.     Much  of  the  material  thus  classified  is  not  obtainable  by  English  readers  in  any  other  work. 

OPINIONS  OF  PROMINENT  MEDICAL  TEACHERS. 


'•  The  compact  size  of  this  dictionary,  its 
clear  type,  and  its  accuracy  are  unfailing 
pointers  to  its  coming  popularity." — John  B. 
Hamilton,  Supervising  Surgeon- General  U. 
S.  Marine  Hospital  Service,   Washington. 

"  It  is  certainly  as  convenient  and  as  useful  a 
volume  as  can  be  found,  regarding  contents  as 
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"  I  have  examined  it  with  considerable  care, 
and  am  very  much  pleased  with  it.  It  is  a 
handy  book  for  reference,  and  so  far  as  I  have 
examined  it,  it  is  accurate  in  every  particular." 
— E.  H.  Bartley,  Prof  of  Chemistry,  Long 
Island  College  Hospital,  Brooklyn. 

'■"  I  consider  this  the  dictionary  of  all  others 
for  the  medical  student,  and  shall  see  that  it  is 
placed  on  our  list  of  text-books." — A.  R. 
Thomas,  M.D.,  Dean  Hahnemann  Medl.  Col, 
Philadelphia. 


"  It  will  be  recommended  among  our  text- 
books in  our  new  catalogue."' — S.  E.  Chaill'e, 
M.D.,  Dean  Medl.  Dept.,  Tulane  Univ.,  New 
Orleans. 

"  Compact,  exact,  up  to  date,  and  the  tables 
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materially  enhance  its  value,  and  help  to  make 
it  worthy  a  place  with  the  classical  books  of 
reference  for  medical  students." — J.  W.  Hoi 
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Directions  for  the  Treatment  of  Urgent  or  Rare  Cases,  embracing  Semeiology, 
Diagnosis,  Prognosis,  Surgery,  Therapeutics,  Toxicology,  Detection  of  Poisons 
by  their  appropriate  tests.  Hygiene,  etc.  By  George  Armatage,  m.r.c.v.s. 
Second  Edition,     32mo.  Boards,  $1.25 

BALLOU.  Veterinary  Anatomy  and  Physiology.  By  Wm.  R.  Ballou,  m.d., 
Prof,  of  Equine  Anatomy,  New  York  College  of  Veterinary  Surgeons,  Physician 
to  Bellevue  Dispensary,  and  Lecturer  on  Genito-Urinary  Surgery,  New  York 
Polyclinic,  etc.  With  29  Graphic  Illustrations.  i2mo.  No.  12  ?  Qiiiz-Compend 
Series.  ?  Cloth,  $1.00.     Interleaved,  for  the  addition  of  notes,  $1.25 

BAR.  Antiseptic  Midwifery.  The  Principles  of  Antiseptic  Methods  Applied  to 
Obstetric  Practice.  By  Dr.  Paul  Bar,  Obstetrician  to,  formerly  Interne  in,  the 
Maternity  Hospital,  Paris.  Authorized  Translation  by  Henry  D.  Fry,  m.d. 
with  an  Appendix  by  the  author.     Octavo.  Cloth,  $1.75 

BARNES.  Lectures  on  Obstetric  Operations,  including  the  Treatment  of  Hemor- 
rhage, and  forming  a  Guide  to  Difficult  Labor.  By  Robert  Barnes,  m.d. 
F.R.c.p.     Fourth  Edition.     Illustrated.     8vo.  Cloth,  ^3.75 

BARRETT.  Dental  Surgery  for  General  Practitioners  and  Students  of  Medicine 
and  Dentistry.  Extraction  of  Teeth,  etc.  By  A.  W.  Barrett,  m.d.  Second 
Edition.     Illustrated       Practical  Series.     \_See  page  ig.']  Cloth,  $1.25 

5 


p.  BLAKISTON,  SON  &-  CO:S 


BARTLEY.  Medical  Chemistry.  Second  Edition.  A  Text-book  for  Medical  and 
I'harniaceutical  Students.  By  E.  H.  Bartley,  m.d.,  Professor  of  Chemistry  and 
Toxicology  at  the  Long  Island  College  Hospital ;  President  of  the  American 
Society  of  Public  Analysts;  Chief  Chemist,  Board  of  Health,  of  Brooklyn,  N.Y. 
Revised  and  enlarged.  With  62  Illustrations.  Glossary  and  Complete  Index. 
423  pages.     i2mo.  Cloth,  $2.50 

BEALE.  On  Slight  Ailments ;  their  Nature  and  Treatment.  By  Lionel  S.  Beale, 
M.I).,  F.R.S.,  Professor  of  Practice,  King's  Medical  College,  London.  Second 
Edition.     Enlarged  and  Illustrated.     8vo.  Cloth,  ^1.25 

Urinary  and  Renal  Diseases  and  Calculous  Disorders.     Hints  on  Diagnosis 
and  Treatment.     Demi-8vo.     356  pages.  Cloth,  $1.75 

The  Use  of  the  Microscope  in  Practical  Medicine.    For  Students  and 
Practitioners,  with  full  directions  for  examining  the  various  secretions,  etc., 
in   the  Microscope.     Fourth  Edition.     500  Illustrations.     8vo.     Cloth,  $7.50 
How  to  "Work  with  the  Microscope.     A  Complete  Manual  of  Microscopical 
Manipulation,    containing    a   full    description    of  many   new   processes    of 
investigation,   with    directions    for    examining   objects   under  the    highest 
powers,  and  for  taking  photographs  of  microscopic  objects.     Fifth  Edition, 
Containing  over  400  Illustrations,  many  of  them  colored.     8vo.    Cloth,  $7.50 
One  Hundred  Urinary  Deposits,  on  eight  sheets,  for  the  Hospital,  Labora- 
tory, or  Surgery.     New  Edition.     4to.  Paper,  $2.00 
BEASLEY'S  Book  of  Prescriptions.     Containing  over  3100  Prescriptions,  collected 
from  the   Practice   of  the   most  Eminent  Physicians  and   Surgeons — English, 
French  and  American ;  a  Compendious  History  of  the  Materia  Medica,  Lists  of 
the  Doses  of  all  Officinal  and  Established  Preparations,  and  an  Index  of  Diseases 
and  their  Remedies.     By  Henry  Beasley.     Sixth  Edition.  Cloth,  $2.25 
Druggists'  General  Receipt  Book.     Comprising  a  copious  Veterinary  Formu- 
lary; Recipes  in   Patent  and   Proprietary  Medicines,  Druggists'  Nostrums, 
etc.;    Perfumery  and  Cosmetics  ;  Beverages,   Dietetic  Articles  and  Condi- 
ments ;  Trade  Chemicals,  Scientific  Processes,  and  an  Appendix  of  Useful 
Tables.     Ninth  Edition.     Revised.  Cloth,  |;2.25 
Pocket  Formulary  and  Synopsis  of  the  British  and  Foreign  Pharmacopoeias. 
Comprising  Standard  and  Approved   Formulas   for   the    Preparations   and 
Compounds  Employed  in  Medical  Practice.    Eleventh  Edition.    Cloth,  ^2.25 
BIDDLE'S  Materia  Medica  and  Therapeutics.    Eleventh  Edition.    For  the  Use  of 
Students  and  Physicians.     By  Prof.  John  B.  Biddle,  m.d..  Professor  of  Materia 
Medica  in  Jefferson  Medical  College,  Philadelphia.     The  Eleventh  Edition,  thor- 
oughly revised,  and  in  many  parts  rewritten,  by  his  son,  Clement  Biddle,  m.d., 
Assistant  Surgeon,  U.    S.  Navy,  and  Henry  Morris,  m.d.,  Demonstrator   of 
Obstetrics  in  Jefferson  Medical  College,  Fellow  of  the  College  of  Physicians,  of 
Philadelphia,  etc.                                                                  Cloth,  $4.25;  Sheep,  $5.00 
BLACK.     Micro-Organisms.     The  Formation  of  Poisons  by  Micro-Organisms.     A 
Biological  study  of  the  Germ  Theory  of  Disease.     By  G.  V.  Black,  m.d.,  d.d.s. 

Cloth,  $1.50 

BLODGETT'S  Dental  Pathology.  By  Albert  N.  Blodgett,  m.d..  Late  Profes- 
sor of  Pathology  and  Therapeutics,  Boston  Dental  College.  33  Illustrations. 
i2mo.  Cloth,  $1.75 

BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experiments.  By 
Charles  L.  Bloxam.  Edited  by  J.  M.  Thompson,  Professor  of  Chemistry  in 
King's  College,  London,  and  A.  G.  Bloxam,  Dem.  of  Chem.,  Royal  Agricultural 
College,  Cirencester.  Seventh  Edition.  Revised  and  Enlarged.  With  330 
Engravings.     8vo.  Cloth,  $4.50;  Leather,  ^5.50 

BOWLBY.    Injuries  and  Diseases  of  the  Nerves,  and  their  surgical  treatment. 

By  Anthony  A.   Bowlby,   f.r.c.s.,   Surgical  Registrar   and    Demonstrator   of 

Practical  Surgery  at  St.  Bartholomew's  Hospital.     Illustrated  by  4  Colored  and 

20  other  full-page  plates.     Svo.  Cloth,  $\.^o 

Surgical  Pathology  and  Morbid  Anatomy.     135  Illustrations.  Cloth,  $2.00 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  7 

BOWMAN.  Practical  Chemistry,  including  analysis,  with  about  loo  Illustrations. 
By  Prof.  John  E.  Bowman.  Eighth  English  Edition.  Revised  by  Prof.  Bloxam, 
Professor  of  Chemistry,  King's  College,  London.  Cloth,  $2.00 

BRUBAKER.  Physiology.  A  Compend  of  Physiology,  specially  adapted  for  the 
use  of  Students  and  Physicians.  By  A.  P.  Brubaker,  m.d..  Demonstrator  of 
Physiology  at  Jefferson  Medical  College,  Prof,  of  Physiology,  Penn'a  College  of 
Dental  Surgery,  Philadelphia,  Fifth  Edition.  Revised,  Enlarged  and  Illus- 
trated.    No.  4,? Quiz- Conpend  Series?     i2mo.  Cloth,  $1.00 

Interleaved  for  the  addition  of  notes,  ;?i.25 

BUCKNILL  AND  TUKE'S  Manual  of  Psychological  Medicine:  containing 
the  Lunacy  Laws,  the  Nosology,  vEtiology,  Statistics,  Description,  Diagnosis, 
Pathology  (including  morbid  Histology)  and  Treatment  of  Insanity.  By  John 
Charles  Bucknill,  m.d.,  f.r.s.,  and  Daniel  Hack  Tuke,  m.d.,  f.r.c.i". 
Fourth  Edition.    Numerous  illustrations.     8vo.  Cloth,  $8.00 

BULKLEY.  The  Skin  in  Health  and  Disease.  By  L.  Duncan  Bulkley,  m.d., 
Attending  Physician  at  the  New  York  Hospital.     Illustrated.  Cloth,  .50 

BUXTON.  On  Anaesthetics.  A  Manual.  By  Dudley  Wilmot  Buxton,  m.r.c.s., 
M.R.C.P.,  Asst.  to  Prof,  of  Med.,  and  Administrator  of  Anzesthetics,  University 
College  Hospital,  London.     Practical  Series.     \_See page  ig.'\  Cloth,  $1.25 

BURNETT.  Hearing,  and  How  to  Keep  It.  By  Chas.  H.  Burnett,  m.d.,  Prof, 
of  Diseases  of  the  Ear,  at  the  Philadelphia  Polyclinic.     Illustrated.        Cloth,  .50 

BYFORD.  Diseases  of  Women.  The  Practice  of  Medicine  and  Surgery,  as 
applied  to  the  Diseases  and  Accidents  Incident  to  Women.  By  W.  H.  Byford, 
a.m.,  m.d..  Professor  of  Gynaecology  in  Rush  Medical  College  and  of  Obstetrics 
in  the  Woman's  Medical  €ollege;  Surgeon  to  the  Woman's  Hospital;  Ex-Presi- 
dent American  Gyntecological  Society,  etc.,  and  Henry  T.  Byford,  m.d..  Sur- 
geon to  the  Woman's  Hospital  of  Chicago;  Gynaecologist  to  St.  Luke's  Hos- 
pital ;  President  Chicago  Gynaecological  Society,  etc.  Fourth  Edition.  Revised, 
Rewritten  and  Enlarged.  With  306  Illustrations,  over  100  of  which  are  original. 
Octavo.     832  pages.  Cloth,  $5.00;  Leather,  $6.00 

On  the  Uterus.     Chronic  Inflammation  and  Displacement.  Cloth,  $1.25 

CAIRD  and  CAT HC ART.  Surgical  Handbook  for  the  use  of  Practitioners  and 
Students.  By  F.  Mitchell  Caird,  m.b.,  f.r.c.s.,  and  C.  Walker  Cathcart, 
M.B.,  F.R.C.S.,  Asst.  Surgeons  Royal  Infirmary.  With  over  200  Illustrations. 
33mo.     400  pages.     Pocket  size.  Leather  covers,  §2.50 

CAMERON.  Oils  and  Varnishes.  A  Practical  Handbook,  by  James  Cameron, 
F.i.c.     With  Illustrations,  Formulae,  Tables,  etc.     i2mo.  Cloth,  $2.50 

Soap  and  Candles.  A  New  Handbook  for  Manufacturers,  Chemists,  Ana- 
lysts, etc.  Compiled  from  all  reliable  and  recent  sources.  54  Ilhistrations. 
i2mo.  Cloth,  $2. 25 

CARPENTER.  The  Microscope  and  Its  Revelations.  By  W.  B.  Carpenter, 
M.D.,  F.R.S.  Seventh  Edition.  Revised  and  Enlarged,  with  over  500  Illustra- 
tions and  Lithographs.  N'e'w  Edition  in  Pres<!. 

CAZEAUX  and  TARNIER'S  Midwifery.  With  Appendix,  by  Munde.  Eighth 
Revised  and  Enlarged  Edition.  With  Colored  Plates  and  numerous  other 
Illustrations.  The  Theory  and  Practice  of  Obstetrics  ;  including  the  Diseases 
of  Pregnancy  and  Parturition,  Obstetrical  Operations,  etc.  By  P.  Cazeaux, 
Member  of  the  Imperial  Academy  of  Medicine,  Adjunct  Professor  in  the  Faculty 
of  Medicine  in  Paris.  Remodeled  and  rearranged,  with  revisions  and  additions, 
by  S.  Tarnier,  m.d..  Professor  of  Obstetrics  and  Diseases  of  Women  and 
Children  in  the  Faculty  of  Medicine  of  Paris.  Eighth  American,  from  the 
Eighth  French  and  First  Italian  Edition.  Edited  and  Enlarged  by  Robert 
J.  Hess,  m.d..  Physician  to  the  Northern  Dispensary,  Phila.,  etc.,  with  an  Ap- 
pendix by  Paul  F.  Munde,  m.d..  Professor  of  Gynaecology  at  the  New  York 
Polyclinic,  and  at  Dartmouth  College;  Vice-President  American  Gyneecological 
Society,  etc.  Illustrated  by  Chromo-Lithographs,  Lithographs,  and  other  Full- 
page  Plates,  seven  of  which  are  beautifully  colored,  and  numerous  Wood  En- 
gravings.    Students'  Edition.    One  Vol.,  8vo.     Cloth,  ^^5.00;  Full  Leather,  $6.00 


8  P.  BLAKISTON,  SON  <S-  CO:S 

CHAVASSE.    The  Mental  Culture  and  Training  of  Children.  Cloth,  $i.oo 

CHURCHILL.  Face  and  Foot  Deformities.  By  Fred.  Churchill,  m.d., 
Ass't  Surgeon  to  the  Victoria  Hospital  for  Sick  Children,  London.  Six  Plain 
and  Two  Colored  Lithographs.     8vo.  Cloth,  $3.50 

CLEVELAND'S  Pocket  Dictionary.  A  Pronouncing  Medical  Lexicon,  containing 
correct  Pronunciation  and  Definition  of  terms  used  in  medicine  and  the  col- 
lateral sciences,  abbreviations  used  in  prescriptions,  list  of  poisons,  their  anti- 
dotes, etc.  By  C.  H.  Cleveland,  m.d.  Thirty-third  Edition.  Very  small 
pocket  size.  Cloth,  .75;  Tucks  with  Pocket,  $1.00 

COHEN  on  Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of 

the  Apparatus  Employed,  etc.     By  J.  Solis-Cohen,  M.D.  CI.,  $1.25 

The  Throat  and  Voice.    Illustrated.     i2mo.  Cloth,  .50 

COLLIE,  On  Fevers.  A  Practical  Treatise  on  Fevers,  Their  History,  Etiology, 
Diagnosis,  Prognosis  and  Treatment.  By  Alexander  Collie,  m.d.,  m.r.c.p., 
Lond.     With  Colored  Plates.    Practical  Series.     See  Page  ig.  Cloth,  $2.50 

COOPER  on  Syphilis  and  Pseudo-Syphilis.  By  Alfred  Cooper,  f.r.c.s..  Sur- 
geon to  West  London  Hospital.     Octavo.  Cloth,  $3.50 

CROOKSHANK.  History  and  Pathology  of  Vaccination.  In  two  volumes. 
\o\.  I,  a  Critical  Inquiry.  Vol.  11  (Edited),  Selected  Essays.  By  Edgar  M. 
Crookshank,  M.B.,  Professor  of  Comparative  Pathology  and  Bacteriology  in 
King's  College,  London  ;  Author  of  a  "  Manual  of  Bacteriology,"  etc.  With  22 
Colored  Plates,  Fac-simile  Letters,  etc.,  and  other  Illustrations.  Royal  8vo. 
Over  1 100  pages.  Handsome  Cloth,  Gilt  Top,  $8.50 

CROCKER.  Diseases  of  the  Skin.  Their  Description,  Pathology,  Diagnosis  and 
Treatment.  By  H.  Radcliffe  Crocker,  m.d..  Physician  to  the  Dept.  of  Skin 
Dis.  University  College  Hospital,  London.     With  Illustrations.  Cloth,  $5.50 

CTJLLINGWORTH.   A  Manual  of  Nursing,  Medical  and  Surgical.    By  Charles 

J.  Cullingworth,    m.d..    Physician  to  St.  Thomas'  Hospital,  London.     Third 

Revised  Edition.     With  18  Illustrations.     i2mo.  Cloth,  .75 

A  Manual  for  Monthly  Nurses.    Third  Edition.    32mo.  Cloth,  .50 

DAVIS.  Biology.  An  Elementary  Treatise.  By  J.  R.  Ainsworth  Davis,  of 
University  College,  Aberystwyth,  Wales.   Thoroughly  Illustrated.    i2mo.      %\xio 

DAVIS.  Clinical  Obstetrical  Chart.  Designed  by  Ed.  P.  Davis,  m.d.,  and  J.  P. 
Crozer  Griffith,  m.d.  Sample  copies  free.  Put  up  in  loose  packages  of  50,  .50 
Price  to  Hospitals,  500  copies,  ^4.00;  1000  copies,  $7.50.  With  name  of  Hos- 
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DAY.  Diseases  of  Children.  A  Practical  and  Systematic  Treatise  for  Practitioners 
and  Students.  By  Wm.  H.  Day,  m.d.  Second  Edition.  Rewritten  and  very 
much  Enlarged.     8vo.     752  pp.     Price  reduced.  Cloth,  $3.00;  Sheep,  $4.00 

On  Headaches.     The  Nature,  Causes  and  Treatment  of  Headaches.     Fourth 
Edition.     Illustrated.     8vo.  Paper,  .75;  Cloth,  51.25 

DERMATOLOGY,  Journal  of    Edited  by  Malcolm  Morris,  m.r.c.s.  London, 
and  D.  G.  Brooke,  m.r.c.s.  Manchester,  Eng.     Monthly.       Per  Annum,  ^3.00 
DILLNBERGER.    On  Women  and  Children.  The  Treatment  of  the  Diseases  Pecu- 
liar to  Women  and  Children.     By  Dr.  Emil  Dillnberger.    i2mo.    Cloth,  $1.50 
DOMVILLE.     Manual  for  Nurses  and  others  engaged  in  attending  to  the  sick.    By 
Ed.  J.  DoMViLLE,  M.D.     Sixth  Ed.     With  Recipes  for  Sick-room  Cookery,  etc. 

Cloth,  .75 

DORAN.  Gynaecological  Operations.  A  Handbook.  By  Alban  Doran,  f.r.c.s., 
Asst.  Surg,  to  the  Samaritan  Free  Hospital  for  Women  and  Children,  London. 
166  Illustrations.     8vo.  Cloth,  ^-5° 

DUCKWORTH.  On  Gout.  Illustrated.  A  treatise  on  Gout.  By  Sir^  Dyce 
Duckworth,  m.d.  (Edin.),  f.r.c.p.,  Physician  to,  and  Lecturer  on  Clinical 
Medicine  at,  St.  Bartholomew's  Hospital,  London.  With  Chromo-lithographs 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  9 

DULLES.  What  to  Do  First,  In  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d. 
Third  Edition,  Enlarged,  with  new  Illustrations.  Cloth.  .75 

DTJRKEE,  On  Gonorrhoea  and  Syphilis.  By  Silas  Durkee,  m.d.  Sixth  Edition. 
Revised  and  Enlarged,  with  Portrait  and  Eight  Colored  Illustrations.    Cloth,  $3.50 

EDIS.  Sterility  in  Women.  By  A.  W.  Edis,  m.d.,  f.r.c.p.,  late  President  British 
Gynaicological  Society;  Senior  Physician,  Chelsea  Hospital  for  Women;  Physician 
to  British  Lying-in  Hospital,  etc.     Illustrated.     8vo.  Cloth,  $1.75 

EDWARDS.     Bright's    Disease.     How  a  Person  Affected  with  Bright's  Disease 

Ought  to  Live.     By  Jos.  F.  Edwards,  m.d      2d  Ed.     Reduced  to        Cloth,  .50 

Vaccination  and  Smallpox.     Showing  the  Reasons  in  favor  of  Vaccination, 

and  the  Fallacy  of  the  Arguments  advanced  against  it,  with  Hints  on  the 

Management  and  Care  of  Smallpox  patients.  Cloth,  .50 

FAGGE.  The  Principles  and  Practice  of  Medicine.  By  C.  Hilton  Fagge,  m.d., 
F.R.C.P.,  F  R.M.C.S.,  Examiner  in  Medicine,  University  of  London;  Physician  to, 
and  Lecturer  on  Pathology  in,  Guy's  Hospital ;  Senior  Physician  to  Evelina  Hos- 
pital for  Sick  Children,  etc.  Arranged  for  the  press  by  Philip  H.  Pve  Smith, 
M.D.,  Lect.  on  Medicine  in  (iuy's  Hospital.  Including  a  section  on  Cutaneous 
Affections,  by  the  Editor;  Chapter  on  Cardiac  Diseases,  by  Samuel  Wilkes,  m.d., 
F.R.S.,  and  Complete  Indexes  by  Robert  Edmund  Carrington.  2  vols.  Royal 
8vo.  Cloth,  $8.00;    Leather,  $10.00  ;    Half  Russia,  $12.00. 

FENWICK'S  Outlines  of  Practice  of  Medicine.  With  Formulae  and  Illustra- 
tions.    By  Samuel  Fenv/ick,  m^.      i2mo.  Cloth,  $1.25 

FIELD.  Evacuant  Medication — Cathartics  and  Emetics.  By  Henry  M.  Field, 
m.d.,  Professor  of  Therapeutics,  Dartmouth  Medical  College,  Corporate  Mem- 
ber Gynaecological  Society  of  Boston,  etc.     i2mo.     288  pp.  Cloth,  gi.75 

FILLEBROWN.  A  Text-Book  of  Operative  Dentistry.  Written  by  invitation 
of  the  National  Association  of  Dental  Faculties.  By  Thomas  Fillebrown,  m.d., 
D.M.D.,  Professor  of  Operative  Dentistry  in  the  Dental  School  of  Harvard  Uni- 
versity;  Member  of  the  American  Dental  Assoc,  etc.    lllus.    8vo.      Clo.,  $2.50 

FLAGG.  Plastics  and  Plastic  Fillings,  as  pertaining  to  the  filling  of  all  Cavities 
of  Decay  in  Teeth  below  medium  in  structure,  and  to  difficult  and  inaccessible 
cavities  in  teeth  of  all  grades  of  structure.  By  J.  Foster  Flagg,  d.d.s.,  Professor 
of  Dental  Pathology  in  Philadelphia  Dental  College.  Third  Revised  Edition. 
With  many  Illustrations.     8vo.  Cloth,  $ij.oo 

FLOWER'S  Diagrams  of  the  Nerves  of  the  Human  Body.  Exhibiting  their 
Origin,  Divisions  and  Connections,  with  their  Distribution  to  the  various  Regions 
of  the  Cutaneous  Surface  and  to  all  the  Muscles.  By  William  H.  Flower, 
F.R.C.S.,  F.R.S.,  Hunterian  Professor  of  Comparative  Anatomy,  and  Conservator 
of  the  Museum  of  the  Royal  College  of  Surgeons.  Third  Edition,  thoroughly 
revised.     With  six  Large  Folio  Maps  or  Diagrams.     4to.  Cloth,  $3.50 

FLUCKIGER.  The  Cinchona  Barks  Pharmacognostically  Considered.  By 
Professor  P^riedrich  Fluckiger,  of  Strasburg.  Translated  by  Frederick  B. 
Power,  ph.d.     With  8  Lithographic  Plates.     Royal  octavo.  Cloth,  $1.50 

FOTHERGILL.  On  the  Heart  and  Its  Diseases.  With  Their  Treatment.  In- 
cluding the  Gouty  Heart.  By  J.  Milner  Fothergill,  m.d..  Member  of  the 
Royal  College  of  Physicians  of  London.     2d  Ed.    Rewritten.     8vo.    Cloth,  $3.50 

FOWLER'S  Dictionary  of  Practical  Medicine.  By  Various  Writers.  An  Ency- 
clopedia of  Medicine.  Edited  by  James  Kingston  Fowler,  m.a.,  m.d.,  f.r.c.p., 
Senior  Asst.  Physician  to,  and  Lecturer  on  Pathological  Anatomy  at,  the  Mid- 
dlesex Hospital  and  the  Hospital  for  Consumption  and  Diseases  of  the  Chest, 
Broinpton,  London.     8vo.    Just  Ready.  Cloth,  $5.00  ;  Half  Morocco,  $6.00 

FOX.  Water,  Air  and  Food.  Sanitary  Examinations  of  Water,  Air  and  Food. 
By  Cornelius  B.  Fox,  m.d.    iio  Engravings.    2d  Ed.,  Revised.        Cloth,  $4.00 


]0  p.  BLAKISTON,  SON  &-  CO:S 

FOX   AND   GOULD.     Compend  on  Diseases  of  the  Eye  and  Refraction, 

including  Treatment  and  Surgery.  By  L.Webster  Fox,  m.d.,  Chief  Clinical 
Assistant,  Ophthalmological  Department,  Jefferson  Medical  College  Hospital ; 
Ophthalmic  Surgeon,  Germantown  Hospital,  Philadelphia  ;  late  Chnical  Assistant 
at  Moorfields,  London,  England,  etc.,  and  Geo.  M.  Gould,  m.d.  Second  Edition. 
Enlarged.  71  Illustrations  and  39  Formulae.  Being  No.  8,  ?  Quiz- Compend  ? 
Series.  Cloth,  $1.00.      Interleaved  for  the  addition  of  notes,  $1.25 

FRANKLAND'S  Water  Analysis.  For  Sanitary  Purposes,  with  Hints  for  the  In- 
terpretation of  Results.     By  E.  Frankland,  m.d.,  f.r.s.     Illustrated.     i2mo. 

Cloth,  $1.00 

FULLERTON.  Obstetrical  Nursing.  A  Handbook  for  Nurses.  Students  and 
Mothers.  By  Anna  M.  Fullerton,  m.d..  Demonstrator  of  Obstetrics  in  the 
Woman's  Medical  College;  Physician  in  charge  of,  and  Obstetrician  and 
Gynaecologist  to,  the  Woman's  Hospital,  Philadelphia,  etc.  34  Illustrations, 
several  of  which  are  original.     i2mo.     212  pages.  Cloth,  $1.25 

GALABIX'S  Midwifery.  A  Manual  for  Students  and  Practitioners.  By  A.  Lew^is 
Galabin,  m.d.,  F.R.C.P.,  Professor  of  Midwifery  at  and  Obstetric  Physician  to, 
Guy's  Hospital,  London.     227  Illustrations.  Cloth,  |;3.oo  ;  Leather,  ;g3. 50 

GARDNER.  The  Brewer,  Distiller  and  Wine  Manufacturer.  A  Handbook  for 
all  Interested  in  the  Manuiacture  and  Trade  of  Alcohol  and  Its  Compounds. 
Edited  by  John  Gardner,  f.c.s.     Illustrated.  Cloth,  $1.75 

Bleaching,  Dyeing,  and  Calico  Printing.  With  Formulae.    Illustrated.     $1.75 

Acetic  Acid,  Vinegar,  Ammonia  and  Alum.     Illustrated.  Cloth,  $1.75 

GARROD.  On  Rheumatism.  A  Treatise  on  Rheumatism  and  Rheumatic  Arthritis. 
By  Archibald  Edward  Garrod,  m.a.  Oxon.,  m.d.,  m.r.c.s.  Eng.,  Asst.  Phy- 
sician, West  London  Hospital.     Illustrated.     Octavo.  Cloth,  ;^6  00 

GIBBES'S  Practical  Histology  and  Pathology.    By  Heneage  Gibbes,  m.b.    i2nio. 

Third  Edition.  Cloth,  $1."]^ 

GILLIAM'S  Pathology.  The  Essentials  of  Pathology ;  a  Handbook  for  Students. 
By  D.  Tod  Gilliam,  m.d..  Professor  of  Physiology,  Starling  Medical  College, 
Columbus,  O.    With  47  Illustrations.    i2mo.  Cloth,  f  2. 00 

GLISAN'S  Modern  Midwifery.  A  Text-book.  By  Rodney  Glisan,  m.d.,  Emeritus 
Professor  of  Midwifery  and  Diseases  of  Women  and  Children  in  Willamette 
Univ.,  Portland,  Oregon.     129  Illus.     8vo.     2d  Edition.  Cloth,  $3.00 

GOODHART  and  STARR'S  Diseases  of  Children.  The  Student's  Guide  to  the 
Diseases  of  Children.  By  J.  F.  Goodhart,  m.d.,  f.r.c.p.,  Physician  to  Evelina 
Hospital  for  Children;  Demonstrator  of  Morbid  Anatomy  at  Guy's  Hospital. 
Second  American  from  the  Third  English  Edition.  Rearranged  and 
Edited,  with  notes  and  additions,  by  Louis  Starr,  m.d..  Clinical  Professor  of  Dis- 
eases of  Children  in  the  University  of  Pennsylvania  ;  Physician  to  the  Children's 
Hospital.     With  many  new  prescriptions.  Cloth,  $3.00;  Leather,  $3.50 

GORGAS'S  Dental  Medicine.  A  Manual  of  Materia  Medica  and  Therapeutics. 
By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s.,  Professor  of  the  Principles  of  Dental 
Science,  Dental  Surgery  and  Dental  Mechanism  in  the  Dental  Department  of 
the  University  of  Maryland.     Thiid  Edition.     Enlarged.     8vo.         Cloth,  $3.50 

GOULD'S  New  Medical  Dictionary.  Including  all  the  Words  and  Phrases  used 
in  Medicine,  with  their  proper  Pronunciation  and  Definitions,  based  on  Recent 
Medical  Literature.  By  George  M.  Gould,  b.a.,  m.d..  Ophthalmic  Surgeon  to 
the  Philadelphia  Hospital,  etc..  With  Tables  of  the  Bacilli,  Micrococci,  Leuco- 
maines,  Ptomaines,  etc.,  of  the  Arteries,  Muscles,  Nerves,  Ganglia  and  Plexuses; 
Mineral  Springs  of  U.  S.,  Vital  Statistics,  etc.     Small  octavo,  520  pages. 

Half  Dark  Leather,  #3.25;  Half  Morocco,  Thumb  Index,  ;?4.25 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  11 

GOWERS,  Manual  of  Diseases  of  the  Nervous  System.  A  Complete  Text-book. 
By  William  R.  Gowers,  m.d..  Prof.  Clinical  Medicine,  University  College. 
London.  Physician  to  National  Hospital  for  the  Paralyzed  and  Epileptic.  341 
Illustrations  and  1360  pages.     Octavo.  New  Edition  Preparing. 

Diagnosis  of  Diseases  of  the  Brain.    8vo.    Second  Ed.    Illus.    Cloth,  $2.00 

Diagnosis  of  Diseases  of  the  Spinal  Cord.    4th  Edition.  Preparing. 

Medical  Ophthalmoscopy.  A  Manual  and  Atlas,  with  Colored  Autotype  and 
Lithographic  Plates  and  Wood-cuts,  comprising  Original  Illustrations  of  the 
changes  of  the  Eye  in  Diseases  of  the  Brain,  Kidney,  etc.  Third  Edition. 
Revised,  with  the  assistance  of  R.  Marcus  Gunn,  f.r.c.s..  Surgeon,  Royal 
London  Ophthalmic  Hospital,  Moorfields.     Octavo.  Cloth,  ^5.50 

Syphilis  and  the  Nervous  System.  Being  the  Lettsomian  Lectures  for  1889. 
8vo.  In  Press. 

GROSS'S  Biography  of  John  Hunter.  John  Hunter  and  His  Pupils.  By  Profes- 
sor S.  D.  Gross,  m.d.     With  a  Portrait.     8vo.  Paper,  .75;  Cloth,  $1.25 

GREENHOW.  Chronic  Bronchitis,  especially  as  connected  with  Gout,  Emphysema, 
aiid  Diseases  of  the  Heart.     By  E.  Headlam  Greenhow,  m.d.     i2mo. 

Paper,  .75;  Cloth,  $1.25 

GRIFFITH'S  Graphic  Clinical  Chart.  Designed  by  J.  P.  Crozer  Griffith, 
M.D.,  Instructor  m  Clinical  Medicine  in  the  University  of  Pennsylvania.  Printed 
in  three  colors.     Sample  copies  free.  Put  up  in  loose  packages  of  50,    .50 

Price  to  Hospitals,  500  copies,* $4.00;  1000  copies,  #7.50.  With  name  of  Hos- 
pital printed  on,  50  cents  extra. 

GROVES  AND  THORP.  Chemical  Technology.  A  new  and  Complete  Work. 
The  Application  of  Chemistry  to  the  Arts  and  Manufactures.  Edited  by 
Charles  E.  Groves,  f.r.s.,  and  Wm.  Thorp,  b.sc,  f.i.c.  In  about  eight  vol- 
umes, with  numerous  illustrations.     Each  volume  sold  separately. 

Vol.  I.  Fuel.  By  Dr.  E.  J.  Mills,  f.r.s..  Professor  of  Chemistry,  Anderson 
College,  Glasgow;  and  Mr.  F.  J.  Rowan,  assisted  by  an  American  expert.  607 
Illustrations  and  4  plates.     Octavo.  Cloth,  7.50;  Half  Morocco,  $9.00 

HABERSHON.  On  Some  Diseases  of  the  Liver.  By  S.  O.  Habershon,  m.d., 
F.R.C.P.,  late  Senior  Physician  to  Guy's  Hospital.     A  New  Edition.     Cloth,  #1.50 

HADDON'S  Embryology.  An  Introduction  to  the  Study  of  Embryology.  For 
the  Use  of  Students.  By  A.  C.  Haddon,  m.a.,  Prof,  of  Zoology,  Royal  College 
of  Science,  Dublin,     igo  Illustrations.  Cloth,  $6.00 

HALE.  On  the  Management  of  Children  in  Health  and  Disease.  A  Book  for 
Mothers.     By  Amie  M.  Hale,  m.d.     New  Enlarged  Edition.     i2mo.     Cloth,  .75 

HARE.  Mediastinal  Disease.  The  Pathology,  Clinical  History  and  Diagnosis  of 
Affections  of  the  Mediastinum  other  than  those  of  the  Heart  and  Aorta,  with 
tables  giving  the  Clinical  History  of  520  cases.  The  essay  to  which  was  awarded 
the  FothergiUian  Medal  of  the  Medical  Society  of  London,  1888.  By  H.  A. 
Hare,  m.d.  (Univ.  of  Pa.),  Demonstrator  of  Therapeutics  and  Instructor  in  Phy- 
sical Diagnosis  in  the  Medical  Department,  and  Instructor  in  Physiology  in  the 
Biological  Department,  Univ  of  Pa.    8vo.    Illustrated  by  Six  Plates.     Cloth,  $2.00 

HARLAN.  Eyesight,  and  How  to  Care  for  It.  By  George  C.  Harlan,  m.d., 
Prof,  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic.     Illustrated.         Cloth,  .50 

HARLEY.  Diseases  of  the  Liver,  With  or  Without  Jaundice.  Diagnosis  and 
Treatment.  By  George  Harley,  m.d.  With  Colored  Plates  and  Numerous 
Illustrations.     8vo.  Price  reduced.     Cloth,  ;^3.oo  ;  Leather,  ;j!;4.oo 

HARRIS.  On  the  Chest.  Including  the  Principal  Affections  of  the  Pleurte,  Lungs, 
Pericardium,  Heart  and  Aorta.  By  Vincent  D.  Harris,  f.r.c.p.,  Physician  to 
the  Victoria  Park  Hospital  for  Diseases  of  the  Chest,  London.  With  55  Illus- 
trations. Cloth,  ;^2.5o 


12  P.  BLAKISTON,  SON  &>  COJS 

HARRIS'S  Principles  and  Practice  of  Dentistry.  Including  Anatomy,  Physi- 
ology, Pathology,  Therapeutics,  Dental  Surgery  and  Mechanism.  By  Chapin  A. 
Harris,  m.d.,  d.d.s.,  late  President  of  the  Baltimore  Dental  College,  author  of 
"  Dictionary  of  Medical  Terminology  and  Dental  Surgery."  Twelfth  Edition. 
Revised  and  Edited  by  Ferdinand  J.  S.  Gorgas,  a.m.,  m.d.,  d.d.s.,  author  ot 
"Dental  Medicine;"  Professor  of  the  Principles  of  Dental  Science,  Dental 
Surgery  and  Dental  Mechanism  in  the  University  of  Maryland.  Two  Full-page 
Plates  and  1086  Illustrations.     1225  pages.    8vo.        Cloth,  $7.00;  Leather,  $8.00 

Medical  and  Dental  Dictionary.  A  Dictionary  of  Medical  Terminology, 
Dental  Surgery,  and  the  Collateral  Sciences.  Fourth  Edition,  carefully 
Revised  and  Enlarged.  By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s..  Prof,  ot 
Dental  Surgery  in  the  Baltimore  College.    8vo.    Cloth,  ;g6.5o  ;  Leather,  $7  5c 

HARTRIDGE.  Refraction.  The  Refraction  of  the  Eye.  A  Manual  for  Students. 
By  GusTAVUS  Haktridge,  f.r.c.s.,  Consulting  Ophthalmic  Surgeon  to  St.  Bar- 
tholomew's Hospital ;  Ass't  Surgeon  to  the  Royal  Westminster  Ophthalmic  Hos- 
pital, etc.     96  Illustrations  and  Test  Types.     Fourth  Edition.  Cloth,  $2.00 

HARTSHORNE.  Our  Homes.  Their  Situation,  Construction,  Drainage,  etc.  By 
Henry  Hartshornk,  m.d.     Illustrated.  Cloth,  .50 

HATFIELD.  Diseases  of  Children.  By  Marcus  P.  Hatfield,  Professor  of 
Diseases  of  Children,  Chicago  Medical  College.  With  a  Colored  Plate.  Being 
No.  14,?  Quiz- Compend?  Series.     i2mo.  Cloth,  $1.00 

Interleaved  for  the  addition  of  notes,  $1.25 

HEADLAND'S  Action  of  Medicines.  On  the  Action  of  Medicines  in  the  System. 
By  F.  W.  Headland,  m.d.     Ninth  American  Edition.     8vo.  Cloth,  $3.00 

HEATH'S  Operative  Surgery.  A  Course  of  Operative  Surgery,  consisting  of  a 
Series  of  Plates,  Drawn  from  Nature  by  M.  Leveille,  of  Paris.  With  Descriptive 
Text  of  Each  Operation.  By  Christopher  Heath,  f.r.c.s..  Holme  Professor 
of  Clinical  Surgery  in  University  College,  London.  Quarto.  Second  Edition. 
Revised.     Sold  by  Subscription.  Cloth,  $12.00 

Minor  Surgery  and  Bandaging.  Ninth  Edition.  Revised  and  Enlarged. 
With  142  Illustrations.     i2mo.  Cloth,  $2.00 

Practical  Anatomy.  A  Manual  of  Dissections.  Seventh  London  Edition. 
24  Colored  Plates,  and  nearly  300  other  Illustrations.  Cloth,  $5.00 

Injuries  and  Diseases  of  the  Jaws.  Third  Edition.  Revised,  with  over 
150  Illustrations.     8vo.  Cloth,  $4.50 

Lectures  on  Certain  Diseases  of  the  Jaws,  delivered  at  the  Royal  College  of 
Surgeons  of  England,  1887.     64  Illustrations.     8vo.  Boards,  ;gi. 00 

HENRY.  Anaemia.  A  Practical  Treatise.  By  Fred'k  P.  Henry,  m.d..  Prof. 
Clinical  Med.  Phila.  Polyclinic,  Physician  to  Episcopal  and  Phila.  Hospitals,  to 
Home  for  Consumptives,  etc.     i2mo.  Half  Cloth,  .75 

HIGGENS'  Ophthalmic  Practice.     A  Manual  for  Students  and  Practitioners.     By 

Charles  Higgens,  f.r.c.s.    Ophthalmic  Surgeon  at  Guy's  Hospital.     Practical 

Series.     See  Page  ig.  Cloth,  $1.75 

Ophthalmic  Practice.     A  Handbook.     Second  Edition.     32mo.       Cloth,  .50 

HILL  AND  COOPER.  Venereal  Diseases.  The  Student's  Manual  of  Venereal 
Diseases,  being  a  concise  description  of  those  Affections  and  their  Treatment. 
By  Berkeley  Hill,  m.d.,  Professor  of  Clinical  Surgery,  University  College,  and 
Arthur  Cooper,  m.d..  Late  House  Surgeon  to  the  Lock  Hospital,  London. 
4th  Edition.     i2mo.  Cloth,  $1.00 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  13 

HOLDEN'S  Anatomy.  A  Manual  of  the  Dissections  of  the  Human  Body.  By 
Luther  Holden,  f.r.c.s.  Fifth  Edition.  Carefully  Revised  and  Enlarged. 
Specially  concerning  the  Anatomy  of  the  Nervous  System,  Organs  of  Special 
Sense,  etc.  By  John  Langton,  f.r.c.s..  Surgeon  to,  and  Lecturer  on  Anatomy 
at,  St.  Bartholomew's  Hospital.     208  Illustrations.     8vo. 

Oilcloth  Covers,  for  the  Dissecting  Room,  $4.50;  Cloth,  $5.00;  Leather,  $6.00 

Human  Osteology.  Comprising  a  Description  of  the  Bones,  with  Colored 
Delineations  of  the  Attachments  of  the  Muscles.  The  General  and  Micro- 
scopical Structure  of  Bone  and  its  Development.  Carefully  Revised.  By 
the  Author  and  Prof.  Stewart,  of  the  Royal  College  of  Surgeons'  Museum. 
With  Lithographic  Plates  and  Numerous  Illustrations.    7th  Ed.    Cloth,  $6.00 

Landmarks.     Medical  and  Surgical.     4th  Edition.     8vo.  Cloth,  $1.25 

HOLLAND.  The  Urine,  the  Common  Poisons  and  the  Milk.  Memoranda,  Chem- 
ical and  Microscopical,  for  Laboratory  Use.  By  J.  W.  Holland,  m.d.,  Professor 
of  Medical  Chemistry  and  Toxicology  in  Jefferson  Medical  College,  of  Philadel- 
phia. Third  Edition.  Revised  and  Enlarged.  Illustrated  and  Interleaved. 
i2mo.  Cloth,  $1.00 

HORWITZ'S  Compend  of  Surgery,  including  Minor  Surgery,  Amputations,  Frac- 
tures, Dislocations,  Surgical  Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with 
Differential  Diagnosis  and  Treatment.  By  Orville  Horwitz,  b.s.,  m.d..  Dem- 
onstrator of  Anatomy,  Jefferson  Medical  College ;  Chief,  Out-Patient  Surgical 
Department,  Jefferson  Medical  College  Hospital.  Third  Edition.  Very  much 
Enlarged  and  Rearranged.  91  Illustrations  and  77  Formulae.  i2mo.  No.g  fQuiz- 
Compend?  Series.  Cloth,  $1.00.     Interleaved  for  the  addition  of  notes,  $1.25 

HXIFELAND.  Xong  Life.  Art  of  Prolonging  Life.  By  C.  W.  Hufeland. 
Edited  by  Erasmus  Wilson,  m.d.     i2mo.  Cloth,  $1.00 

HUGHES.  Compend  of  the  Practice  of  Medicine.  Fourth  Edition.  Revised  and 
Enlarged.  By  Daniel  E.  Hughes,  m.d..  Demonstrator  of  Clinical  Medicine  a 
Jefferson  Medical  College,  Philadelphia.-  In  two  parts.  Being  Nos.  2  and  j" 
f  Quiz-  Compend  f  Series. 

Part  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases  of  the  Stomach, 
Intestines,  Peritoneum,  Biliary  Passages,  Liver,  Kidneys,  etc.,  and  General 
Diseases,  etc. 

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vous System  ;  Diseases  of  the  Blood,  etc. 

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Physicians'  Edition. — In  one  volume,  including  the  above  two  parts,  a  sec- 
tion on  Skin  Diseases,  and  an  index.  Fourth  revised,  enlarged  Edition. 
462  pages.  Full  Morocco,  Gilt  Edge,  $2.50 

HUMPHREY.  A  Manual  for  Nurses.  Including  general  Anatomy  and  Physiology, 
management  of  the  sick  room,  etc.  By  Laurence  Humphrey,  m.a.,  m.b., 
M.R.C.S.,  Assistant  Physician  to,  and  Lecturer  at,  Addenbrook's  Hospital,  Cam- 
bridge, England.     i2mo.     Illustrated.     242  pages.  Cloth,  $1.25 

JACOBSON.  Operations  of  Surgery.  By  W.  H.  A.  Jacobson,  b.a.  oxon., 
F.R  C.S.,  Eng. ;  Ass't  Surgeon.  Guy's  Hospital;  Surgeon  at  Royal  Hospital  for 
Children  and  Women,  etc.     With  over  200  Illust.      Cloth,  $5.00  ;  Leather,  $6.00 

JAMES  on  Sore  Throat.  Its  Nature,  Varieties  and  Treatment,  including  its  Con- 
nection with  other  Diseases.  By  Prosser  James,  m.d.  Fourth  Edition,  Re- 
vised and  Enlarged.     Colored  Plates  and  Wood-cuts.       Paper  .75  ;  Cloth,  $1.25 

JONES'  Aural  Surgery.  A  Practical  Handbook  on  Aural  Surgery.  By  H. 
Macnaughton  Jones,  m.d.,  Surgeon  to  the  Cork  Ophthalmic  and  Aural  Hospital. 
Illustrated.    SecondEdition,  with  new  Wood  Engravings.    i2mo.         Cloth,  $2.75 


14  P.  BLAKISTON,  SON  &*  CO:S 

KEATING.  How  to  Examine  for  Life  Insurance.  A  Practical  Handbook.  Bv 
John  M.  Keating,  President  of  the  Association  of  Life-Insurance  Medical  Direc- 
tors.    With  3  Full-page  Plates  and  other  Illustrations.     8vo.        Cloth,  net,  $2.00. 

KIRKES'  Physiology.  [Authorized  Edition.)  A  Handbook  of  Physiology. 
Twelfth  London  Edition,  Revised  and  Enlarged.  By  W.  Morrant  Baker, 
M.D.     460  Illustrations.     i2mo.     880  Pages.  Cloth,  $4.00;  Leather,  ^5  00 

LANDIS'  Compend  of  Obstetrics  ;  especially  adapted  to  the  Use  of  Students  and 
Physicians.  By  Henry  G.  Landis,  m.d.,  Professor  of  Obstetrics  and  Diseases 
of  Women,  in  Starling  Medical  College,  Columbus,  Ohio.  Fourth  Edition. 
Enlarged.     With  Many  Illustrations.     A'^.  j  ?  Quiz-Competid?  Series. 

Cloth,  $r.oo;  interleaved  for  the  addition  of  Notes,  $1.25 

LANDOIS.  A  Text-Book  of  Human  Physiology  ;  including  Histology  and  Micro- 
scopical Anatomy,  with  special  reference  to  the  requirements  of  Practical  Medi- 
cine. By  Dr.  L.  Landois,  Professor  of  Physiology  and  Director  of  the  Physio- 
logical Institute  in  the  University  of  Greifswald.  Third  American,  translated 
from  the  Sixth  German  Edition,  with  additions,  by  Wm.  Stirling,  m.d.,  d.sc., 
Brackenbury  Professor  of  Physiology  and  Histology  in  Owen's  College,  Man- 
chester ;  Examiner  in  Physiology  in  University  of  Oxford,  England.  With  692 
Illustrations.     8vo.  Cloth,  $6.50;  Leather,  $7.50 

LEBER  AND  ROTTENSTEIN.  Dental  Caries  and  Its  Causes.  An  Investigation 
inio  the  Influence  of  Fungi  in  the  Destruction  of  the  Teeth.  By  Drs.  Leber 
and  ROTTENSTEIN.     Illustrated.  Paper,  .75  ;  Cloth,  $1.25 

LEE.  The  Microtomist's  Vade  Mecum.  Second  Edition.  A  Handbook  of 
Methods  of  Microscopical  Anatomy.  By  Arthur  Bolles  Lee,  Asst.  in  the  Rus- 
sian Laboratory  of  Zoology,  at  Villefranche-sur-Mer  (Nice).  660  Formulas,  etc. 
Enlarged  and  Revised.  Cloth,  $4.00 

LEFFM ANN'S  Compend  of  Chemistry,  Inorganic  and  Organic-  Including  Urine 
Analysis.  By  Henry  Leffmann,  m.d.,  Prof,  of  Chemistry  and  Metallurgy  in 
the  Penna.  College  of  Dental  Surgery,  and  in  the  Wagner  Free  Institute  of 
Science,  Philadelphia.  No.  10  ? Quiz- Compend ?  Series.  Third  Edition.  Re- 
written and  Adapted  for  Students  of  Medicine  and  Dentistry.     i2mo. 

Cloth,  $1.00.     Interleaved  for  the  addition  of  Notes,  $1.25 

LEFFMANN  &  BEAM.  Examination  of  Water  for  Sanitary  and  Technical  Pur- 
poses. By  Henry  Leffmann,  m.d.,  Professor  of  Chemistry  and  Metallurgy, 
Penna.  College  of  Dental  Surgery,  Hygienist  and  Food  Inspector  Penna.  State 
Board  of  Agriculture,  etc.;  and  William  Beam,  a.m.,  formerly  Chief  Chemist 
B.  &  O.  R.  R.  Second  Edition.  Enlarged.  Illustrated.  i2mo.  Cloth,  $1.25 
Progressive  Exercises  in  Practical  Chemistry.  A  Laboratory  Handbook. 
Iliubtrated.     i2mo.  Cloth,  $1.00 

LEG6  on  the  Urine.  Practical  Guide  to  the  Examination  of  the  Urine,  for 
Practitioner  and  Student.  By  J.Wickham  Legg,  m.d.  Sixth  Edition,  Enlarged. 
Illustrated.     i2mo.  Cloth,  .75 

LEWERS.  On  the  Diseases  of  Women.  Second  Edition.  With  146  Engravings. 
Practical  Series.     See  Page  ig.     i2mo.  Cloth,  $2.50 

LEWIN  on  Syphilis,  The  Treatment  of  Syphilis.  By  Dr.  George  Lewin,  of 
Berlin.  Translated  by  Carl  Proegler,  m.d.,  and  E.  H.  Gale,  m.d..  Surgeons 
U.  S.  Army.     Illustrated.     i2mo.  Paper,  .75  ;  Cloth,  $1.25 

LEWIS,  (BEVAN).  Mental  Diseases.  A  text-book  having  special  reference  to  the 
Pathological  aspects  of  Insanity.  By  Bevan  Lewis,  l.r.c.p.,  m.r.c.s.,  Medi- 
cal Director,  West  Riding  Asylum,  Wakefield,  England.  18  Lithographic  plates 
and  other  Illustrations.     8vo.  Cloth,  $6.00 

LIEBREICH'S  Atlas  of  Ophthalmoscopy,  composed  of  12  Chromo-Lithographic 
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Third  Edition.     410.  '  Boards,  $15.00 

LINCOLN.    School  and  Industrial  Hygiene.    By  D.  F.  Lincoln,  m.d.    Cloth,  .50 
LIZARS,  (JOHN).     On  Tobacco.     The  Use  and  Abuse  of  Tobacco.  Cloth,  .50 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  15 

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the  Correct  Definition  and  Pronunciation  of  all  Words  and  Terms  in  General 
Use  in  Medicine  and  the  Collateral  Sciences,  with  an  Appendix,  containing 
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LUCKES.  Hospital  Sisters  and  their  Duties.  By  Eva  C.  E.  Lucres,  Matron  to 
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MAC  MUNN.     Chemistry  of  Urine.     Illustrated.     Outlines  of  the  Clinical 
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cuts and  Plate  of  Spectra.     Octavo.  $3-00 
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MACNAMARA.  On  the  Eye.  A  Manual  of  the  Diseases  of  the  Eye.  By  C. 
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Numerous  Colored  Plates,  Diagrams  of  Eye,  Wood-cuts,  and  Test  Types. 
Demi  8vo.  Preparing. 

MACALISTER'S  Human  Anatomy.  800  Illustrations.  A  New  Text-book  for 
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in  Zoology  and  Comparative  Anatomy,  University  of  London;  formerly  Professor 
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which  are  original.     Octavo.  Cloth,  $7.50;   Leather,  $8.50 

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scopical Examination  of  Air.  By  J.  D.  Macdonald,  m.d.  With  25  Litho- 
graphic Plates,  Reference  Tables,  etc.    Second  Ed.,  Revised.     8vo.    Cloth,  $2.75 

MACKENZIE.  The  (Esophagus,  Nose,  Naso-Pharynx,  etc.  By  Sir  Morell 
Mackenzie,  m.d..  Senior  Physician  to  the  Hospital  for  Diseases  of  the  Chest 
and  Throat,  London.  Illus.  Being  Vol.  II  of  the  First  Edition  of  his  Treatise 
on  the  Throat  and  Nose.     Complete  in  itself.  Cloth,  $3.00;  Leather,  $4.00 

The  Pharmacopoeia  of  the  Hospital  for  Diseases  of  the  Throat  and  Nose. 
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the   Class.    By  John  Marshall,  f.r.s.,  f.r.c.s.,  Professor  of  Anatomy  to  the 
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Textures  and  Organs. 


16  P.  BLAKISTON,  SON  &'  CO.'S 

MARSHALL  &  SMITH.  On  the  Urine.  The  Chemical  Analysis  of  the  Urine. 
By  John  Marshall,  m.d.,  and  Prof.  Edgar  F.  Smith,  of  the  Chemical  Labora- 
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Numerous  Illustrations.     l2mo.  Cloth,  $i.oc 

MAXWELL.  Terminologia  Medica  Polyglotta.  By  Dr.  Theodore  Maxwell, 
assisted  by  others  in  various  countries.     8vo.  Cloth,  $4.00 

The  object  of  this  work  is  to  assist  the  medical  men  of  any  nationality  in  reading  medical  literature  written 
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Italian,  Spanish,  Russian  and  Latin. 

MAYS'  Therapeutic  Forces  ;  or,  The  Action  of  Medicine  in  the  Light  of  the  Doc- 
trine of  Conservation  of  F'orce.     By  Thomas  J.  Mays,  m.d.  Cloth,  $1.25 

Theine  in  the  Treatment  of  Neuralgia.    Being  a  Contribution  to  the  Thera- 
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Symptoms  of  Pregnancy,  Obstetric  Operations,  Diseases  of  the  Puerperal  State, 
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tion.    Revised  and  Enlarged.     With  145  Illustrations.     8vo.  Cloth,  |;2.oo 

MEDICAL  Directory  of  Philadelphia  and  Camden,  1889.  Containing  lists  of 
Physicians  of  all  Schools  of  Practice,  Dentists,  Veterinarians,  Druggists  and 
Chemists,  with  information  concerning  Medical  Societies,  Colleges  and  Associa- 
tions, Hospitals,  Asylums,  Charities,  etc.  Morocco,  Gilt  edges,  $2.50 

MEIGS.  Milk  Analysis  and  Infant  Feeding.  A  Practical  Treatise  on  the  Ex- 
amination of  Human  and  Cows'  Milk,  Cream,  Condensed  Milk,  etc.,  and 
Directions  as  to  the  Diet  of  Young  Infants.  By  Arthur  V.  Meigs,  m.d..  Physi- 
cian to  the  Pennsylvania  Hospital,  Philadelphia.     i2mo.  Cloth,  $1.00 

MEIGS  and  PEPPER  on  Children.  A  Practical  Treatise  on  the  Diseases  of 
Children.  By  J.  Forsyth  Meigs,  m.d..  Fellow  of  the  College  of  Physicians  of 
Philadelphia,  etc.,  etc.,  and  William  Pepper,  m.d..  Professor  of  the  Principles 
and  Practice  of  Medicine  in  the  Medical  Department,  University  of  Pennsyl- 
vania.    Seventh  Edition.  Cloth,  $5.00;  Leather,  $6.00 

MERRELL'S  Digest  of  Materia  Medica.  Forming  a  Complete  Pharmacopoeia  for 
the  use  of  Physicians,  Pharmacists  and  Students.  By  Albert  Merrell,  m.d. 
Octavo.  Half  dark  Calf,  $4.00 

MEYER.  Ophthalmplogy.  A  Manual  of  Diseases  of  the  Eye.  By  Dr.  Edouard 
Meyer,  Prof,  a  L'Ecole  de  la  Faculte  de  Medicine  de  Paris,  Chev.  of  the  Legion 
of  Honor,  etc.  Translated  from  the  Third  French  Edition,  with  the  assistance 
of  the  author,  by  A.  Freedland  Fergus,  m.b..  Assistant  Surgeon  Glasgow 
Eye  Infirmary.  With  270  Illustrations,  and  two  Colored  Plates  prepared 
under  the  direction  of  Dr.  Richard  Liebreich,  m.r.cs..  Author  of  the  "Atlas 
of  Ophthalmoscopy."     8vo.  Cloth,  ;J4.5o  ;  Leather,  $5.50 

MILLER  and  LIZAR'S  Alcohol  and  Tobacco.  Alcohol.  Its  Place  and  Power. 
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M.D.     The  two  essays  in  one  volume.  Cloth,  $1.00;  Separate,  each  .50 

MILLS.  Fuel  and  Its  Applications.  By  E.  J.  Mills,  d.sc,  f.r.s.,  and  E.  J. 
Rowan,  c.E.  (See  Groves  and  Thorp  Technology.)  8vo.  Clo.,  $7.50;  Half  Mor.  $9.00 

MONEY.  On  Children.  Treatment  of  Disease  in  Children,  including  the  Outlines 
of  Diagnosis  and  the  Chief  Pathological  Differences  between  Children  and 
Adults.  By  Angel  Money,  m.d.,  m.r.c.p.,  Asst.  Physician  to  the  Hospital  for 
Sick  Children,  Great  Ormond  St.,  and  to  the  Victoria  Park  Chest  Hospital,  Lon- 
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MEDICAL  AND  SCIENTIFIC  PUBLIC  A  TIONS.  17 

MORTON  on  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Correction  of  its  Errors. 
With  Chapter  on  Keratoscopy,  and  Test  Types.  By  A.  Morton,  m.b.  Third 
Edition,  Revised  and  Enlarged.  Cloth,  $i.oo 

MTJRRELL.     Massotherapeutics.     Massage  as  a  Mode  of  Treatment.     By  Wm. 
MuRRELL,  M.D.,  F.R.C.P.,  Lecturer  on  Pharmacology  and  Therapeutics  at  West- 
minster Hospital.     5th  Edition.    Revised.    i2mo.  Cloth,  $1.50 
Chronic  Bronchitis  and  its  Treatment.    {Authorized  Edition^    A  Clinical 
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MiJTER.    Practical  and  Analytical  Chemistry.    By  John  Muter,  f.r.s.,  f.c.s., 
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NEW  SYDENHAM  SOCIETY  Publications.     Three  to  Six  Volumes  published 
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OBERSTEINER,  The  Anatomy  of  the  Ceiitral  Nervous  Organs.  A  Guide  to  the 
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of  the  University  of  Vienna.  Translated,  with  annotations  and  additions,  by 
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OPHTHALMIC  REVIEW.  A  Monthly  Record  of  Ophthalmic  Science.  Published 
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OSTROM.  Massage  and  the  Original  Swedish  Movements.  Their  Apphcation 
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By  Kurre  W.  Ostrom,  from  the  Royal  University  of  Upsala,  Sweden  ;  Instructor 
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PAGE'S  Injuries  of  the  Spine  and  Spinal  Cord,  without  apparent  Lesion  and  Ner- 
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PARKES'  Practical  Hygiene.  By  Edward  A.  Parkes,  m.d.  The  Seventh  Re- 
vised and  Enlarged  Edition.     With  Many  Illustrations.     Svo.  Cloth,  $4.50 

PARKES.  Hygiene  and  Public  Health.  A  Practical  Manual.  By  Louis  C. 
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PARRISH'S  Alcoholic  Inebriety.  From  a  Medical  Standpoint,  with  Illustrative 
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PARVIN'S  Winckel's  Diseases  of  Women.     (See  Winckel,  page  25). 

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Nurses  of  the  Philadelphia  Hospital.     By  Theophilus  Parvin,  m.d..  Professor 
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PENNSYLVANIA  Hospital  Reports.  Edited  by  a  Committee  of  the  Hospital 
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18  P.  RLAKISTON,  SON  &*  CO:S  PUBLICATIONS. 

PHYSICIAN'S  VISITING  LIST.    Published  Annually.     Thirty-ninth  Year  of  its 
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•I  .<  ^       1         f  Jan.  to  Tune )  ,,         .,         .. 

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-'  I  July  to  Dec.  j  •         •  3 

,,  .,  «      1         f  Tan.  to  Tune]  „         „         ,, 

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FEREIRA'S  Prescription  Book,  Containing  Lists .  of  Terms,  Phrases,  Contrac- 
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PIGGOTT  Copper  Mining  and  Copper  Ore,     i2mo.  Cloth,  $1.00 

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POWER,  HOLMES,  ANSTIE  and  BARNES  (Drs,).  Reports  on  the  Progress  of 
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POTTER,  A  Handbook  of  Materia  Medica,  Pharmacy  and  Therapeutics,  in- 
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cluding over  600  Prescriptions  and  Formulse.  By  Samuel  O.  L.  Potter,  m.a,, 
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TfHE  PRACTICAL  SERIES 


THREE  NEW  VOLUMES. 


PARKES.  Hygiene  and  Public  Health.  A  Practical  Manual.  By  Louis  C. 
Parkes,  M.D.,  D.P.H.,  London  Hospital;  Fellow  of  the  Sanitary  Institute; 
Assistant  Professor  of  Hygiene  and  Public  Health,  at  University  College,  etc. 
l2mo.     Second  Edition.  Cloth,  $2.50 

LEWERS.    On  the  Diseases  of  Women.    A  Practical  Treatise.     By  Dr.  A.  H. 

N.  Lewers,  Assistant  Obstetric  Physician  to  the  London  Hospital ;  and  Phy- 
sician to  Out-patients,  Queen  Charlotte's  Lying-in  Hospital ;  Examiner  in  Mid- 
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146  Engravings.     Second  Edition,  Revised.  Cloth,  112.50 

BUXTON.  On  Anaesthetics.  A  Manual  of  their  Uses  and  Administration.  By 
Dudley  Wilmot  Buxton,  m.d.,  b.s.,  Ass't  to  Prof,  of  Med.,  and  Administrator 
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Second  Edition  in  Press. 


MONEY.  On  Children.  Treatment  of 
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BARRETT.  Denial  Surgery  for  Gen- 
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COLLIE  On  Fevers.  A  Practical  Treat- 
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RALFE.    Diseases  of  the  Kidney  and 

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REEVES.     Bodily    Deformities    and 

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rence. With  an  Introduction  by  L.  E.  Sayre,  ph.g..  Professor  of  Pharmacy  in, 
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SCHNEE.  Diabetes,  its  Cause  and  Permanent  Cure.  From  the  standpoint  of  ex- 
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vised and  Enlarged  by  the  author.     Octavo.  Cloth,  $2.oc 

SEWELL.  Dental  Surgery,  including  Special  Anatomy  and  Surgery.  By  Henry 
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SMITH'S  Wasting  Diseases  of  Infants  and  Children.  By  Eustace  Smith,  m.d., 
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Edition,  Enlarged.     8vo.  Cloth,  $3.00 

Clinical  Studies  of  Diseases  in  Children.    Second  Edition.       Cloth,  $2.50 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  of  all  the  Princi- 
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SMITH  (TYLER).  Lectures  on  Obstetrics.  Delivered  at  St.  Mary's  Hospital. 
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STAMMER.  Chemical  Problems,  with  Explanations  and  Answers.  By  Karl 
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22  P.  BLAKISTON,  SON  &*  CO:S 

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Outlines  of  Practical  Histology.    A  Manual  for  Students.    With  344  Illus- 
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STOCKEN'S  Dental  Materia  Medica.  Dental  Materia  Medica  and  Therapeutics, 
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STKAHAN.  Extra-Uterine  Pregnancy.  The  Diagnosis  and  Treatment  of  Extra- 
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Belfast  Union  Infirmary  and  Fever  Hospital.     Octavo.  Cloth,  $1.50 

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SUTTON.  Ligaments.  Their  Nature  and  Morphology.  By  John  Bland  Sutton, 
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SWAIN.  Surgical  Emergencies,  together  with  the  Emergencies  Attendant  on 
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SWANZY.  Diseases  of  the  Eye  and  their  Treatment.  A  Handbook  for  Physi- 
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SYMONDS.  Manual  of  Chemistry,  for  the  special  use  of  Medical  Students.  By 
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Index  of  Dental  Periodical  Literature     8vo.  Cloth,  $2.00 
TALBOT.    Irregularities  of  the  Teeth,  ^nd  Their  Treatment.    By  Eugene  S. 
Talbot,  m.d.,  Professor  of  Dental  Surgery  Woman's    Medical    College,  and 
Lecturer  on  Dental  Pathology  in  Rush  Medical  College,  Chicago.     Second  Edi- 
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(169  of  which  are  original).     261  pages.  Cloth,  $3.00 
TANNER'S  Index  of  Diseases  and  their  Treatment.    By  Thos.  Hawkes  Tanner, 
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sity College.     Third  Edition.     With  87  Engravings.     8vo.  Cloth,  $3.50 
Urinary  Organs.     Diseases  of  the  Urinary  Organs.    Containing  32  Lectures. 
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On  the  Prostate.     Diseases  of  the  Prostate.     Their  Pathology  and  Treatment. 

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TILT'S  Change  of  Life  in  Women,  in  Health  and  Disease.  A  Practical  Treatise 
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Tilt,  M.D.     Fourth  London  Edition.     Svo.  Paper  cover,  .75  ;  Cloth,  $1.25 

TOMES'  Dental  Anatomy.  A  Manual  of  Dental  Anatomy,  Human  and  Compara- 
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Dental  Surgery.  A  System  of  Dental  Surgery.  By  John  Tomes,  f.r.s. 
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24  P.  BLAKISTON,  SON  &^  CO.'S 

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VAN  NUYS  on  The  Urine.  Chemical  Analysis  of  Healthy  and  Diseased  Urine, 
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WOODY.  Essentials  of  Chemistry  and  Urinalysis.  By  Sam  E.  Woody,  a.m., 
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WYNTER  and  WETHERED.  Clinical  and  Practical  Pathology.  A  Manual 
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istrar and  late  Dem.  of  Anat,  and  Chem.  at  the  Middlesex  Hospital,  and 
Frank  J.  Wethered,  m.d.,  Asst.  Phys.  to  the  City  of  London  Hospital  for  Dis. 
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WYTHE  on  the  Microscope.  A  Manual  of  Microscopy  and  Compendium  of  the 
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WALSHAMS    PRACTICAL    SURGERY.     A  Manual  for  Students  and  Physicians.     By  Wm.  J. 

Walsham,  M.D.,  Asst.  Surgeon  to,  and  Demonstrator  of  Surgery  in,  St.  Bartholomew's  Hospital;  Sur- 

ceon  to  Metropolitan  Free  Hospital,  London,  etc.     236  Illust.     656  pp.  t. 

^  Cloth,  ^3.00;  Leather,  ^3.50 

■'^'""•'•'while^iwden'tiy  intended  to  be  a  text-book  for  students,  and  therefore  small  in  size  and  compactly  written,  is  neverthe- 
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PARvTn'S-WINCKEL'S  diseases  of  women.  Second  Edition.  A  Treatise  on  the  Dis- 
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by  Theophilus  Parvin,  m.d.,  Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  Jeffer- 
son Medical  College.     Illustrated  by  150  fine  Engravings  on  Wood,  most  of  which  are  new.     760  pp. 

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Examiner  in  Midwifery  to  the  Conjoint  Examining  Board  of  England.     227  Illustrations.     753  pages. 

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"The  illustrations  are  mostly  new  and  well  executed,  and  we  heartily  commena  this  book  as  far  superior  to  any  manual 

YEO'S  MANUAL  OF  PHYSIOLOGY.  Fourth  Edition.  A  New  Text-book  for  Students.  By 
Gerai  d  F  Yeo,  m.d.,  F.R.C.S.,  Professor  of  Physiology  in  King's  College,  London.  321  Illustra- 
tions and  a  Glossary.     758  pages.  Cloth,  $3.00;  Leather,  $3.50 

RICHTER'S  organic  CHEMISTRY.  By  Prof.  Victor  von  Richter,  University  of  Breslau. 
Authorized  translation.  First  American,  from  the  Fourth  German  Edition.  By  Edgar  F.  Smith,  m.d., 
PH  D  ,  Translator  of  Richter's  Inorganic  Chemistry;  Prof,  of  Chemistry  in  Wittenberg  College,  Spring- 
field, Ohio;  formerly  in  the  Laboratories  of  the  University  of  Pennsylvania;  Member  of  the  Chemical 
Societies  of  Berlin  and  Paris,  of  the  Academy  of  Natural  Sciences  of  Philadelphia,  etc.  Illustrattd. 
pacres  Cloth,  ^3  00;  Leather.  $3.50 

GOODHARTAND  STARR,  DISEASES  OF  children.  Second  Edition.  By  J.  F.Goodhart, 
M  d  Physician  to  the  Evelina  Hospital  for  Children ;  Assistant  Physician  to  Guy's  Hospiial,  London. 
Secj'nd  American  from  third  English  Edition.  Revised  and  Edited  by  Louis  Starr,  m.d.,  Clinical 
Professor  of  Diseases  of  Children  in  the  Hospital  of  the  University  of  Pennsylvania,  and  Physician  to  the 
Children's  Hospital,  Phila.  With  many  new  Prescriptions  and  Direcuons  for  making  Artificial  Human 
Milk,  for  the  Artificial  Digestion  of  Milk,  etc.     760  pages.  Cloth,  $3.00;  Leather,  33-5° 

From  The  New  York  Medical  Record.  ,        ,         ,  , ,_  .  .     ri>u-  «i =i,ob# 

•'  As  it  is  said  of  some  men,  so  it  might  be  said  ot  some  books,  that  they  are  '  born  to  greatness.  This  new  volume  has 
we  believe  a  mission,  particularly  in  the  hands  of  the  young  members  of  the  profession  In  these  days  of  prolixity  in  medical 
liter.iture    it  is  refreshing  to  meet  with  an  author  who  knows  both  what  to  say  and  when  he  has  said  it.  .      ,  r,^, 

WARI'nG'S  practical  THERAPEUTICS.  Fourth  Edition.  A  Manual  of  Practical  Thera- 
peutics,  considered  with  reference  to  Articles  of  the  Materia  Medica.  Containing,  also,  an  Index  of 
Diseases  with  a  list  of  Medicines  applicable  as  Remedies,  and  a  full  Index  of  the  Medicines  and 
Preparations  noticed  in  the  work.  By  Edward  John  Waring,  m.d.,  f.r.c.p.,  f.l  s.  etc.  4tb 
Edition  Rewritten  and  Revised.  Edited  by  Dudley  W.  Buxton,  m.d,  Asst.  to  the  Prof,  of  Medicine 
at  University  Colle-e  Hospital;  Member  of  the  Royal  College  of  Physicians  of  London.     666  pages. 

Cloth,  33.00;  Leather,  33.5c 

''''''•<  A?a%f:rnf  ?.l:r!llt'-f.^:Z:t  account  of  the  several  complete  indexes  added  to  this  edition.     It  was  deseryedl, 
popular'in  former  editions,  and  will  be  more  so  in  the  one  before  "^,  oiiaccoimt  of  the  careful  arrangement  of  the  ^"bjects 

REESE'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY.  Second  Edition.  By  John  J, 
Rees'^  M  D  Professor  of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania  ;  late 
President  of  the  Medical  Jurisprudence  Society  of  Philadelphia;  Physican  to  St.  Joseph's  Hospital; 
Member  of  the  Colleee  of  Physicians  of  Phila.;  Corresponding  Membtr  of  the  New  York  Medico-Legal 
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THE   MOST   PRACTICAL  SERIES  OF  TEXT-BOOKS- 


JUST  PUBLISHED.     THIRD  EDITION. 

HUMAN  PHYSIOLOGY. 

By  LANDOIS  and  STIRLING. 

With  692  Illustrations. 

THIRD    AMERICAN,   FROM    THE    SIXTH    GERMAN    EDITION. 

A  Text-Book  of  Human  Physiology,  including  Histology  and  Microscopical  Anaromy, 
with  special  reference  to  the  requirements  of  Practical  Medicine.  -  By 
Dr.  L.  Landois,  Professor  of  Physiology  and  Director  of  the  Physiological  Institute, 
University  of  Greifswald.  Translated  from  the  Fifth  German  Edition,  with  addi- 
tions by  Wm.  Stirling,  m.d.,  sc.d.,  Brackenbury,  Professor  of  Physiology  and 
Histology  in  Owen's  College  and  Victoria  University,  Manchester;  Examiner  in 
the  Honors'  School  of  Science,  University  of  Oxford,  England.  Third  Edition, 
revised  and  enlarged.  692  Illustrations. 
"A   BRIDGE    BETWEEN    PHYSIOLOGY   AND    PRACTICAL    MEDICINE." 

One  Volume.    Eoyal  Octavo.    Cloth,  $6.50 ;  Leather,  $7.50. 

Frofn  the  Prefaces  to  the  English  Edition. 
The  fact  that  Prof.  Landois'  book  has  passed  through  four  large  editions  in  the  original  since  1S80,  and 
that  in  barely  six  months'  time  a  second  edition  of  the  English  has  been  called  for,  shows  that  in  some 
special  way  it  has  met  a  want.  The  characteristic  which  has  thus  commended  the  work  will  be  found 
mainly  to  lie  in  its  eminent  practicability;  and  it  is  this  consideration  which  has  induced  me  to  undertake  the 
task  of  putting  it  into  English.  Landois'  work,  in  fact,  forms  a  Bridge  between  Physiology  and  the  Practice 
of  Medicine.  It  never  loses  .Mght  of  the  fact  that  the  student  of  to  day  is  the  practicing  physician  of 
to-morrow.  In  the  same  way,  the  work  offers  to  the  busy  physician  in  practice  a  ready  means  of  refreshing 
his  memory  on  the  theoretical  aspects  of  Medicine.  He  can  pass  backward  from  the  examination  of  patho- 
logical phenomena  to  the  normal  processes,  and,  in  the  study  of  these,  find  new  indications  and  new  lights 
for  the  appreciation  and  treatment  of  the  cases  under  consideration.  With  this  object  in  view,  all  the 
methods  of  investigation  which  may,  to  advantage,  be  used  by  the  practitioner,  are  carefully  and  fully 
described.  Many  additions,  and  about  one  hundred  illustrations,  have  been  introduced  into  this  second 
English  edition,  and  the  whole  work  carefully  revised. 

PRESS  NOTICES. 

"  Most  effectivaly  aids  the  busy  physician  to  trace  from  morbid  phenomena  back  the  course  of  divergence  from 
heahhy  physical  operacions,  and  to  gather  in  this  way  new  lights  and  novel  indications  for  the  comprehension  and  treatment 
ot  the  maladies  with  which  he  is  called  upon  to  cope." — American  Journal  of  Medical  Sciences. 

"  I  know  of  no  book  which  is  its  equal  in  the  applications  to  the  needs  of  clinical  medicine." — Prof.  Harrison  Allen,  late 
Professor  of  I'hysiolos^y,  University  of  Pejinsylvania. 

"  We  have  no  hesitation  in  saying  that  this  is  the  work  to  which  the  Practitioner  will  turn  whenever  he  desires  light 
thrown  upon  the  phenomena  of  a  complicated  or  important  case." — Edinburgh  Medical  Journal. 

"  So  great  are  the  advantages  offered  by  Prof.  Landois"  I'ext-Book,  from  the  exhaustive  and  eminently  practical 
manner  in  which  the  subject  is  treated,  that  it  has  passed  through  four  large  editions  in  the  same  number  of  years.  .  .  . 
Dr.  Stirling's  annotations  have  materially  added  to  the  value  of  the  work.  Admirably  adapted  for  the  Practitioner.  .  .  . 
With  this  Text-book  at  command,  NO  Student  could  fail  in  his  examination." — The  Lancet. 

"One  of  the  most  practical  works  on  Physiology  ever  written,  forming  a  '  bridge  '  between  Physiology  and  Practical 
Medicine.  .  .  .  Its  chief  merits  are  its  completeness  and  conciseness.  .  .  .  The  additions  by  the  Editor  are  able  and  judicious. 
.  .   .   Excellently  clkar,  attractive  and  svcciNcr."— Sr  it  is/t  Medical  Journal. 

"  The  great  subjects  dealt  with  are  t-ealed  in  an  admirably  clear,  terse,  and  happily  illustrated  manner." — Practitioner. 

"  Unquestionably  the  most  admirable  exposition  of  the  relations  of  Human  Physiology  to  Practical  Medicine  ever  laid 
before  English  readers" — Students'  Journal. 

"As  a  work  of  reference,  Landois  and  Stirling's  Treatise  ought  to  take  the  foremost  place  among  the  text- 
books in  the  English  language.     The  wood-cuts  are  noticeable  for  their  number  and  beauty." — Glasgo'ju  Medical  Journal. 

"  Landois'  Physiology  is,  without  question,  the  best  text-book  on  the  subject  that  has  ever  been  written." 
— New    York  Medical  Record. 

"  The  chapter  on  the  Brain  and  Spinal  Cord  will  be  a  rrost  valuable  one  for  the  general  reader,  the  translator's  notes  adding 
not  a  little  to  its  importance.  The  sections  on  Sight  and  Hearmg  are  exhaustive.  .  .  .  The  Chemistry- of  the  Urine  is  thoroughly 
considered.  ...  In  its  present  form,  the  value  of  the  original  has  been  greatly  increased.  .  .  .  The  text  is  smooth,  accurate, 
and  unusually  fiee  from  Germanisms  ;  in  fact,  it  is  good  English." — New  York  Medical  Journal. 

"  It  is  not  for  the  physiological  student  alone  that  Prof.  Landois'  book  possesses  great  value,  for  it  has  been  addressed 
TO  THE  practitioner  OF  MEDICINE  as  well,  who  will  find  here  a  direct  application  of  physiological  to  pathological  processes." 
Medical  Bulletin. 

P.  BLAKISTON,  SON  &  CO.,  Publishers,  1012  Walnut  St.,  Philadelphia. 


DISEASES  OF  THE  SKIN, 

BY  T.  MCCALL  ANDERSON,  M.D., 

Professor  of  Clinical  Medicine  in  the  University  of  Glasgow. 
ASSISTED  BY 
Dr.  Tames  Christie,  Sec'y  London  Epidemiological  Society  for  Indian  Ocean  and  East  Africa ;  Mem. 
Medical  Soc.  of  Bombay,  etc.  Dr.  Hector  C.  Cameron,  Surgeon  and  Lecturer  to  Western  Infirmary, 
Glasgow;  Surgeon  to  Glasgow  Hospital  for  Children,  etc.  William  Macewen,  M.B.,  M.D.,  Lecturer  on 
Systematic  and  Clinical  Surgery,  Royal  Infirmary;  Surgeon  to  Royal  Infirmary  and  Children's  Hospital, 
Glasgow,  etc. 

WITH  COLORED  PLATES  AND  NUMEROUS  WOOD  ENGRAVINGS. 

Octavo.     650  Pages.     Cloth,  $4.50  ;  Leather,  $5.50. 
A  treatise  on  Diseases  of  the  Skin,  with  reference  to  Diagnosis  and  Treatment, 
including  an  Analysis  of  11,000  Consecutive  Cases.     Thoroughly  illustrated  by  new  and 
handsome  wood  engravings,  and  several  colored  and  steel  plates  prepared,  under  the 
direction  of  the  author,  from  special  drawings  by  Dr.  John  Wilson. 

PARTICULARLY  STRONG  IN  TREATMENT. 

J5@°"  Special  attention  is  given  to  the  Differential  Diagnosis  of  Skin  Diseases  and  to  the 
treatment.  There  are  over  150  prescriptions,  which  will  serve  as  hints  to  the  physician 
in  dealing  with  obstinate  and  chronic  cases. 

There  has  been  no  complete  treatise  on  Dermatology  issued  for  several  years  ;  Professor 
Anderson  has,  therefore,  chosen  an  opportune  tin:ie  to  publish  his  book. 


ILLUSTRATING  ONE  OF  THE  DISEASES  OF  THE  HaIR  [See  Hs.t.page  7). 

For  nearly  twenty-five  years  Professor  Anderson  has  been  a  general  practitioner  and  a 
hospital  physician,  with  unusual  opportunities  for  the  study  of  this  class  of  diseases,  though 
not  a  "specialist,"  as  the  term  is  understood.  His  experience  is,  therefore,  of  great 
value,  and  the  physician  will  feel  that,  in  consulting  this  work,  he  is  reading  the  expe- 
riences of  a  man  situated  as  himself— with  the  same  difficulties  of  diagnosis  and  treatment, 
and  who  has  surmounted  them  successfully.  We  believe  this  to  be  a  valuable  feature  of 
the  book  that  will  be  recognized  at  once;  for  it  is  undoubtedly  a  fact  that  a  work  like 
the  present  contains  much  practical  information  and  many  hints  not  to  be  found  else- 
where. Professor  Anderson  is  particularly  happy  in  illustrating  the  impor- 
tant relations  subsisting  between  the  general  economy  and  its  covering,  and 
his  ideas  of  pathology  and  therapeutics,  including  a  consideration  of  all  the  general 
and  local  manifestations  of  the  common  diseases  of  the  economy  which  are  manifested 
upon  the  surface,  will  find  many  appreciative  readers. 

Diseases  of  the  hair  receive  full  systematic  treatment. 

"We  welcome  Dr  Anderson's  work  not  only  as  a  friend,  but  as  a  benefactor  to  the  profession,  because  the  author  has 
stricken  off  mediaeval  shackles  of  insuperable  nomenclature  and  made  crooked  ways  straight  in  the  diagnosis  and  treatment  of 
this  hitherto  but  little  understood  class  of  diseases.  The  chapter  on  Eczema  is,  alone,  worth  the  price  of  the  book.  —NashvitU 
Medical  Aews. 


PQUIZ-COMPENDS.? 

A  Series  of  Practical  Manuals  for  the  Physician  and  Student. 

Compiled  in  accordance  with  the  latest  teachings  of  prominent  lecturers 
and  the  most  popular  Text-books. 

Bound  in  Cloth,  each  $i.oo.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

They  form  a  most  complete,  practical  and  exhaustive  set  of  manuals,  containing  information 
nowhere  else  collected  in  such  a  practical  shape.  Thoroughly  up  to  the  times  m  every  respect, 
containing  many  new  prescriptions  and  formulte,  and  over  300  illustrations,  many  of  which  have 
been  drawn  and  engraved  specially  ior  this  series.  The  authors  have  had  large  experience  as 
quiz-masters  and  attaches  of  colleges,  with  exceptional  opportunities  for  noting  the  most  recent 
advances  and  methods.  The  arrangement  of  the  subjects,  illustrations,  t\pes,  etc.,  are  all  of  the 
most  approved  form.  They  are  constantly  being  revised,  so  as  to  include  the  latest  and  best 
teachings,  and  can  be  used  by  students  of  any  college  of  medicine,  dentistry  and  pharmacy. 
No.   I.     Human    Anatomy.      Fifth    Edition,  including    Visceral   Anatomy,  formerly 

published  separately.      16  Lithograph  Plates,  Tables,  and  117  Illustrations.     By 

Samuel  O.  L.  Potter,  m.a  ,  m.d.,  late  A.  A.  Surgeon,  U.  S.  Army.    Professor  of  Practice, 

Cooper  Med.  College,  San  Francisco. 
Nos.  2  and  3.     Practice  of   Medicine.      Fourth    Edition,   Enlarged.      By  Daniel   E. 

Hughes,  m.d.,  late  Demonstrator  of  Clinical  Medicine  in  Jefferson  Med.  College,  Phila. ; 

Physician-in  Chief,  Philadelphia  Hospital.     In  two  parts. 
Part  I. — Continued,  Eruptive  and    Periodical  Fevers,  Diseases  of  the  Stomach,  Intestines,  Peritoneum, 
Biliary  Passages,  Liver,  Kidneys,  etc.  (including  Tests  for  Urine),  General  Diseases,  etc. 

Part  II.  — Diseases  of  the  Respiratory  System  (including  Physical  Diagnosis),  Circulatory  System  and 
Nervous  System  ;  Diseases  of  the  Blood,  etc. 

*»*  These  little  books  can  be  regarded  as  a  full  set  of  notes  upon  the  Practice  of  Medicine,  containing  the 
Synonyms,  Definitions,  Causes,  Symptoms,  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each  disease,  and  including 
a  number  of  prescriptions  hitherto  unpublished. 

No.  4.  Physiology,  including  Embryology.  Fifth  Edition.  By  Albert  P.  Brubaker, 
M.D.,  Prof,  of  Physiology,  Penn'a  College  of  Dental  Surgery;  Demonstrator  of  Physiology 
in  Jefferson  Med.  College,  Phila.     Revised,  Enlarged  and  Illustrated. 

No.  5.  Obstetrics.  Illustrated.  Fourth  Edition.  For  Physicians  and  Students.  By 
Henry  G.  Landis,  m.d.,  Prof,  of  Obstetrics  and  Diseases  of  Women,  in  Starling  Medical 
College,  Columbus.     Revised  Edition.     New  Illustrations. 

No.  6.  Materia  Medica,  Therapeutics  and  Prescription  Writing.  Fifth  Revised 
Edition.  With  especial  Reference  to  the  Physiological  Action  of  Drui.'s,  and  a  complete 
article  on  Prescription  Writing.  Based  on  the  Last  Revision  (Sixth)  of  the  U.  S.  Pharma- 
copoeia, and  including  many  unofficinal  remedies.  By  Samuel  O.  L.  Potter,  m..\.,  m.d., 
late  A.  A.  Surg.  U.  S.  Army ;  Prof,  of  Practice,  Cooper  Med.  College,  San  Francisco.  5th 
Edition.     Improved  and  Enlarged. 

No.  7.  Gynaecology.  A  Compend  of  Diseases  of  Women.  By  Henry  Morris,  m.d.. 
Demonstrator  of  Obstetrics,  JcHerson  Medical  College,  Philadelphia.     Many  Illustrations. 

No.  8.  Diseases  of  the  Eye  and  Refraction,  including  Treatment  and  Surgery.  By  L. 
Webster  Fox,  m.d.,  Chief  Clinical  Assistant  Opthalmological  Dept.,  Jefferson  Medical 
College,  etc.,  and  Geo.  M.  Gould,  m  d.     71  Illustrations,  39  Formulpe.      2d  Edition. 

No.  9.  Surgery,  Minor  Surgery  and  Bandaging.  Illustrated.  Fourth  Edition.  Includ- 
ing Fractures,  Wounds,  Dislocations,  Sprains,  Amputations  and  other  operations;  Inflam- 
mation, Suppuration,  Ulcers,  Syphilis,  Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear, 
Bladder,  Testicles,  Anus,  and  other  Surgical  Diseases.  By  Orville  Horwitz,  a.m.,  m.d., 
Demonstrator  of  Surgery,  Jefferson  Medical  College.     84  FormulcC  and  136  Illustrations. 

No.  10.  Medical  Chemistry.  Third  Edition.  Inorganic  and  Organic,  including  Urine 
Analysis.  For  Medical  and  Dental  Students.  By  Henry  Lkffmann,  m.d..  Prof,  of  Chem- 
istry in  Penn'a  College  of  Dental  Surgery,  Phila.     Third  Edition.     Revised  and  Enlarged. 

No.  II.  Pharmacy.  Based  upon  "Remington's  Text-Book  of  Pharmacy."  By  F.  E. 
Stew.^rt,  m.d.,  ph.g.,  Professor  of  Pharmacy,  Powers  College  of  Pharmacy;  late  Quiz- 
Master  at  Philadelphia  College  of  Pharmacy.     Third  Edition.     Revised. 

No.  12.  Veterinary  Anatomy  and  Physiology.  Illustrated.  By  Wm.  R.  Ballou,  m.d., 
Prof,  of  Equine  Anatomy,  New  York  College  of  Veterinary  Surgeons,  etc.     29  Illustrations. 

No.  13.  Dental  Pathology  and  Dental  Medicine,  Containing  all  the  most  noteworthy 
points  of  interest  to  the  Dental  student.  By  Geo.  W.  Warren,  d.d.s..  Clinical  Chief, 
Penn'a  College  of  Dental  Surgery,  Philadelphia.     Illus. 

No.  14.  Diseases  of  Children.  By  Marcus  P.  Hatfield,  Professor  of  Diseases  of 
Children,  Chicago  Medical  College.     With  Colored  Plate. 

These  books  are  constantly  revised  to  keep  up  with  the  latest  teachings  and  discoveries. 


"ITSTANDS  WITHOUT  AN  EQUAL  AS  THE  MOST  COMPLETE  WORK  ON  PRACTICE  IN 
THE  ENGLISH  LANGUAGE."— AViu  York  Medical  Journal. 

FAGGE'S  PRACTICE  OF  MEDICINE. 

Two  Large  Royal  Octavo  Volumes.     Containing  over  1900  Pages. 

PRICE,  HANDSOMELY   BOUND   IN  CLOTH,  S8.00. 

The  Principles  and  Practice  of  Medicine. 

By  CHARLES  HILTON  FAGGE,  M.D.,  F.R.C.P.,  F.R.M.C.S., 

Rxaniiner  in  Medicine,  University  of  London;  Physician  to,  and  Lecturer  on  Pathology  in,  Guy' s  Hospital, 
Senior  Physician  to  Evelina  Hospital /or  Sick  Children,  etc. 

EDITED  AND  ARRANGED  FOR  THE  PRESS 

By  p.  H.  Pye-Smith,  M.D.,  F.R.C.P., 

Lecturer  on  Medicine  in  Guy's  Hospital,  London,  etc., 

WITH  A  SECTION  ON  CUTANEOUS  AFFECTIONS,  BY  THE  EDITOR,  A  CHAPTER  ON  CAR- 
DIAC DISEASES,  BY  SaMUEL  WilKES,  M.  D.,  F.  R.  S.,  AND  TWO  INDEXES,  ONE  OF 
AUTHORS   AND   ONE  OF   SUBJECTS,  BY   ROBERT   EdmUND    CaRRINGTON. 

Two  Volumes.  Royal  Octavo.  1900  Pages. 

Price  in  Cloth,  $8.00.    Full  Leather,  $10.00.     Half  Morocco,  $12.00.    Half  Russia,  $12.00. 


It  is  based  on  laborious  researches  into  the  pathological  and  clinical  records  of 
Guy's  Hospital,  London,  during  the  twenty  years  in  which  the  author  has  held  office 
there  as  Medical  Registrar,  as  Pathologist,  and  as  Physician.  Familiar  beyond  most, 
if  not  all,  of  his  contemporaries,  with  modern  medical  literature,  a  diligenl  reader  of 
French  and  German  periodicals.  Dr.  Fagge,  with  his  remarkably  retentive  memory  and 
methodical  habits,  was  able  to  bring  to  his  work  of  collection  and  criticism  almost 
unequaled  opportunities  of  extensive  experience  in  the  wards  and  dead  house.  The 
result  is  that  which  will  probably  be  admitted  to  be  a  fuller,  more  original,  and  more 
elaborate  text-book  on  medicine  than  has  yet  appeared.  It  is  the  first  of  importance 
emanating  from  Guy's  Hospital,  and  the  only  two-volume  work  on  the  Practice  of 
Medicine  that  has  been  issued  for  a  number  of  years.  Several  subjects,  such  as 
Syphilis,  that  are  usually  omitted  or  but  slightly  spoken  of  in  a  general  work  of  this 
character,  receive  full  attention. 

Dr.  Walter  Moxon,  one  of  Dr.  Fagge's  contemporaries,  and  a  great  personal 
friend,  writes  of  him,  in  a  recent  number  of  the  London  Lancet : — 

"  Fagge  was,  to  my  mind,  the  type  of  true  medical  greatness,  I  believe  he  was  capable  of  any  kind  of 
excellence.  His  greatness  as  a  physician  became  evident  to  observers  of  character  very  soon  after  his  brilliant 
student  career  had  placed  him  on  the  staff  of  Guy's  Hospital:  he  did  not  merely  group  already  known  facts, 
but  he  found  new  facts.  Former  volumes  of  Guy's  Hospital  Reports  contain  ample  and  most  valuable  proof  of 
his  greatness  as  a  physician.  His  power  of  observation  was  sustained  by  immense  memory,  and  brought  into 
action  by  vivid  and  constant  suggestiveness  of  intelligence.  He  was  a  physician  by  grace  of  nature,  and  being 
gifted  with  a  quickness  of  perception,  a  genius  for  clinical  facts  and  a  patience  in  observation,  he  was  at  once 
recognized  as  a  successful  practitioner  and  a  leading  figure  in  the  hospital  and  among  the  profession. 


New  Text-Books. 


Macalister's  Human  Anatomy.     8i6  Illustrations  (400  of 
which  are  Original).     Just  Ready. 

A  NEW  TEXT  BOOK  for  Students  and  Practitioners,  Systematic  and  Topographical, 
including  the  Embryology,  Histology  and  Morphology  of  Man.  With  special 
reference  to  the  requirements  of  Practical  Surgery  and  Medicine. 
By  Alex.  Macalister,  m.d.,  f.r.s.,  f.s.a.,  Professor  of  Anatomy  in  the  Univer- 
sity of  Cambridge,  England;  Examiner  in  Zoology  and  Comparative  Anatomy, 
University  of  London ;  formerly  Professor  of  Anatomy  and  Surgery,  University 
of  Dublin.     With  8i6  Illustrations,  400  of  which  are  original.     Octavo. 

Cloth,  $7.50;  Leather,  $8.50 

;  *^*  Professor  Macalister's  reputation  as  an  Anatomist  and  Zoologist  is  such  that 
nothing  need  be  said  of  the  scientific  value  of  this  book.  Regardmg  the  illustrations, 
printing  and  binding  we  may  say,  however,  that  the  workmanship  is  of  the  best 
character  in  every  respect.  No  e.xpense  has  been  spared  to  make  a  handsome  vol- 
ume, the  400  original  illustrations  adding  greatly  to  its  appearance  as  well  as  to  its 
practical  value  as  a  working  book  for  students  and  physicians. 

Potter's  Materia  Medica,  Pharmacy  and  Therapeutics. 
Second  Edition.     Revised  and  Enlarged. 

A   HANDBOOK   OF   MATERIA    MEDICA,  PHARMACY   AND   THERAPEUTICS — including 

the  Physiological  Action  of  Drugs,  Special  Therapeutics  of  Diseases,  Official  and 
Extemporaneous  Pharmacy,  etc.  By  Sam'l  O.  L.  Potter,  m.a.,  m.d.,  Professor 
of  the  Practice  of  Medicine  in  Cooper  Medical  College,  San  Francisco;  Late 
A.  A.  Surgeon,  U.  S.  Army,  Author  of  "Speech  and  its  Defects,"  and  the  "Quiz- 
Compends"  of  Anatomy  and  Materia  Medica,  etc.  Revised,  Enlarged  and  Im- 
oroved.     Octavo.      Wi//i  Thumb  Index  in  each  copy. 

Cloth,  $4.00;  Leather,  ^5.00 

"  The  author  has  aimed  to  embrace  in  a  single  voliime  the  essentials  of  practical  materia 
medica  and  iherapeutics,  and  has  produced  a  book  small  enough  for  easy  carriage  and  easy  ref- 
erence, large  enough  to  contain  a  carefully  digested,  but  full,  clear  and  well-arranged  mass  of 
information.  He  has  not  adhered  to  any  pharmacopoeia,  as  is  the  case  of  certain  recent  manuals, 
thereby  limiting  his  woik,  and  in  this  day  of  new  remedies  causing  c  nstant  disappnintment,  but 
has  broui;ht  it  up  to  date  in  the  most  sausfactory  way.  No  new  remedy  of  any  acknowledged 
value  is  omitted  from  this  li^t.  Under  each  the  section  on  physiological  action  and  therapeuucs 
has  been  written  with  care.  ...  In  the  enumeration  of  drugs  suited  to  different  disorders  a 
very  successful  eflort  at  discrimination  has  been  made,  both  in  the  stage  of  disease  and  in  the 
cases  peculiarly  suited  to  the  remedy.  It  is  no  mere  list  of  diseases  followed  by  a  catalogue 
of  drugs,  but  is  a  digest  of  modern  therapeutics,  and  as  such  will  prove  cf  immense  use  to  its 
possessor." — The  Therapeutic  Gazette. 

Winckel's  Obstetrics.     Original  Illustrations. 

A  TEXT-BOOK   OF   OBSTETRICS,  INCLUDING  THE   PATHOLOGY   AND   THERAPEUTICS 

OF  THE  PUERPERAL  STATE.  By  Dr.  F.  Winckel,  Professor  of  Gynaecology, 
and  Director  of  the  Royal  University  Clinic  for  Women,  in  Munich.  Authorized 
Translation,  by  J.  Clifton  Edgar,  m.d.,  Adjunct  Professor  to  the  Chair  of 
Obstetrics,  Medical  Dept.,  University,  of  the  City  of  New  York,  with  nearly  200 
handsome  illustrations,  the  majority  of  which  are  original  with  this  work.   Octavo. 

Cloth,  ;g6.oo;  Leather,  ;g7.oo 


PUBLISHED   ANNUALLY. 


1891. 


NOW  READY.     40th  YEAR. 


Yhe  Physician's  Visiting  List. 


(LINDSAY  &  BLAKISTON'S.) 

CONTENTS. 


A1.MANAC  for  1890  and  1891. 

Tablb  of  Signs  to  be  used  in  keeping  accounts. 

Marshall  Hall's  Ready  Method  in  Asphyxia. 

Poisons  and  Antidotes,  revised  for  1890. 

The  Metric  or  French  Decimal  System  of 
Weights  and  Measures. 

Dose  Table,  revised  and  rewritten  for  1890,  by  Hc- 
bart  Amory  Hare,  m.d.  Demonstrator  of  Thera- 
peutics, University  of  Pennsylvania. 

List  of  New  Remedies  for  1890,  by  same  autTior. 

Aids  to  Diagnosis  and  Treatment  of  Diseases  of 
the  Eye,  Dk.  L.  Webster  Fox,  Clinical  Asst.  Eye 
Dept.,  Jefferson  Medical  College  Hospital,  and  G. 
M.  Gould,  m.d. 

Diagram  Showing  Eruption  of  Milk  Teeth,  Dr. 
Louis  Starr,  Prof,  of  Diseases  of  Children,  Univer- 
sity Hospital,  Philadelphia. 


Posological  Table,  Meadows. 

Disinfectants  and  Disinfecting. 

Examination  of  Urine,  Dr.  J.  DAi.Ariv,  Sase J  ujiot 
Tyson's  "  Practical  Examination  of  Urine."  6in 
Edition. 

Incompatibility,  Dr.  S.  O.  L.  Potter. 

A  New  Complete  Table  for  Calculating  the 
Period  of  Utero-Gestation. 

Sylvester's  Method  for  Artificial  Respiration. 
Illustrated. 

Diagram  of  the  Chest. 

Blank  Leaves,  suitably  ruled,  for  Visiting  Lists, 
Monthly  Memoranda,  Addresses  of  Patients  and 
others  ;  Addresses  of  Nurses,  their  references,  etc. ; 
Accounts  asked  for;  Memoranda  of  Wants  ;  Obstet- 
ric and  Vaccination  Engagements;  Record  of  Births 
and  Deaths  ;  Cash  Account,  etc. 


REGULAR   EDITION. 


For  25  Patients  weekly. 
50 

75         " 

TOO  "  " 

50  " 

100  "  " 

For  25  Patients  weekly. 
50 

50        " 


Tucks,  pockets  and  Pencil,  $i.oo 


2  Vols.  {|t;°S"^} 

(  July  to  Dec.  j 

2  Vols     1  Jan.  to  June  I 
2  vols,    jjyiyto  jjgj,_| 

INTERLEAVED  EDITION. 

Interleaved,  tucks  and  Pencil, 


2  Vols. 


J  Jan.  to  June 
( July  to  Dec. 


1.25 
1.50 
2.00 

2.50 
3.00 


1.25 
1.50 

3.00 


PERPETUAL  EDITION,  without  Dates. 
No.  1.     Containing  space  for  over  1300  names,  with  blank  page  opposite  each 

Visiting  List  page.  Bound  in  Red  Leather  cover,  with  pocket  and  Pencil,  $1.25 
No.  2.     Containing  space   for   2600  names,  with  blank  page  opposite   each 

Visiting  List  page.     Bound  like  No.  i,  with  Pocket  and  Pencil 1.50 

MONTHLY  EDITION,  without  Dates. 

No.  1.     Bound  without  Flap  or  Pencil 75 

No.  2.         "      with  Tucks,  Pencil,  etc., l.oc 

These  lists,  without  dates,  can  be  commenced  at  any  time,  and  used  until  full, 
and  are  particularly  useful  to  young  physicians  unable  to  estimate  the  number  of 
patients  they  may  have  during  the  first  years  of  Practice,  and  to  physicians  in  locali- 
ties where  epidemics  occur  frequently.  In  the  Monthly  Edition  the  patient's  name 
has  to  be  entered  but  once  each  month. 

"  For  completeness,  compactness,  and  simplicity  of  arrangement  it  is  excelled  by  none  in  the  market." — iV.  Jf 
Medical  Record. 

"  The  book  is  convenient  in  form,  not  too  bulky,  and  in  every  respect  the  very  best  Visiting  List  published.' 
—  Canada  Medical  and  Surgical  Journal. 

"  After  all  the  trials  made,  there  are  none  superior  to  it." — Gaillard's  Medical  Journal. 

"  The  most  popular  Visiting  List  extant." — Buffalo  Medical  and  Surgical  Journal. 

"  We  have  used  it  for  years,  and  do  not  hesitate  to  pronounce  it  equal,  if  not  superior,  to  any." — Southert 
Clinic, 

This  is  not  a  complicated  system  of  keeping  accounts,  but  a  plain,  systematic 
record  which,  with  the  least  expenditure  of  time  and  trouble,  keeps  an  accurate  and 
concise  list  of  daily  visits,  engagements,  etc. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stxl 

RD32J15C.1 

The  operations  of  surgery 

IIHUiilliiiUUttHHItfW 


